ATMA 2012

Convention Registration Form

Last *

First *

Middle

Name : *

Spouse :

Address1 : *

Address2 :

Country : *

City : *

State : *

Zip : *

Phone :

Mobile : *

Email : *

Convention Registration - Patron

Includes room for three nights, CME and all other fees for the entire convention; meals, sight seeing and entertainment

Member and Physician Spouse/Guest $1695.00

Member and non-Physician Spouse/Guest $1495.00

Convention Registration - Regular

NO room for three nights, includes CME and all other fees for the entire convention; meals, sight seeing and entertainment

Member and Physician Spouse/Guest $995.00

Member and non-Physician Spouse/Guest $795.00

Member Only $495.00

Non-Member Registration with CME $550.00

Additional Guest (other than spouse and no CME) $300.00

Convention Registration - Children

Children 11 to 18 years -($100 per person)

Name :

Age :

Name :

Age :

Name :

Age :

Name :

Age :

Children 10 years and under -($40 per person)

Name :

Age :

Name :

Age :

Name :

Age :

Name :

Age :

Sub Total :

$ 0

Not registering for CME(one) Deduct $100.00

Not registering for CME(two) Deduct $200.00

Sub Total :

One Day Registration

Friday only (Lunch, Cruise and Dinner – $125 for Adult, $50 for Children of Age 11 to 18, $20 for Children of Age < 10 )

Name :	Age :	Meal Type :
Name :	Age :	Meal Type :
Name :	Age :	Meal Type :
Name :	Age :	Meal Type :

Saturday only (Lunch, Dinner and Gala Entertainement – $150 per Adult, $50 for Children of Age 11 to 18, $20 for Children of Age < 10)

Name :	Age :	Meal Type :
Name :	Age :	Meal Type :
Name :	Age :	Meal Type :
Name :	Age :	Meal Type :

Sub Total :

Total :

Please Submit Registration for Preview and Payment
Submit

For any questions regarding registration or if you do not find the category to purchase please email joycenyhan@aol.com

Payment Summary

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Fee

Total

Total:

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Expiry Date

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Ticket buyer – Billing Details

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last Name

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