DMG CME

DMGCME 2013 Summer Conference

Online Registration Form

Skin, Bones, Hearts & Private Parts!

June 10-14, 2013 • Disney's Coronado Springs Resort
Walt Disney World® Resort, Florida

 

 


10% Discount
For Active Duty
Military

 

Nation’s Most Sought-
After SPEAKERS!

 

 

Bring a Colleague
& Save 10%!

 

 

 

Revolutionary Education & Entertainment
Date:

GENERAL INFORMATION:

Registration includes breakfasts, refreshment breaks and access to sessions. Registration badges will be required for admission to all events. Payment is due with registration form and must be submitted according to to the above dates to qualify for the corresponding rate. Materials can only be guaranteed to pre-registered attendees - be sure to register early.

Please complete and submit the registration form below. One registration form per person. If you prefer, you may print this form with your browser and fax or mail to DMGCME.

 

In keeping with our Go Green Initiatives, attendees will have on-line access to session handouts prior to event. A convenience fee of $15 will apply for those desiring printed copies of the 6 tracks on Tues-Thurs. Deadline to order handouts is 2 weeks prior to the conference start date (5/27/2013).

 

In accordance with the Americans with Disablilites Act, please notify the DMGCME office if you have any special needs.
PERSONAL INFORMATION:
Note that items marked with an "*" are required fields.

*First Name: A value is required.  Invalid entry.
Middle Initial: Invalid entry.
*Last Name: A value is required.  Invalid entry.
Suffix (ex: Jr., Sr.): Invalid entry.
Nickname on Badge:
*Credentials (i.e. PA-C, FNP, etc.): A value is required.  Invalid entry.
*Specialty: A value is required.  Invalid entry.
*Address Line 1: A value is required.
Address Line 2:
*City: A value is required.
*State: Please select a state.
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*Email Address: A value is required.  Invalid entry.
*How did you learn about the conference:
(Check all that apply.)
 AANP SmartBrief E-blasts
 AAPA CME Calendar
 AAPA Medical Watch
 Advance for NPs & PAs
 AdvancedPracticeJobs.com
 Clinical Advisor
 Conference Brochure
 DMGCME.com Website
 Emails from healthjobsnationwide.com
 ENPNetwork website
 Facebook
 JAAPA
 LinkedIn
 mdconferencefinder website
 News-line
 NP Forum
 PA Exchange
 PA Forum
 PA Jobsite
 PA Professional
 Twitter
 Other (please specify)    

SUMMER REGISTRATION INFORMATION:
*Please select one registration option from the choices below:
SELECT
CATEGORY		 On/Before Mar 15 After Mar 15 After April 15

  Board Review (Monday ONLY)

 $395 $425 $445

  Full Conference(Tues-Fri)

 $645 $695 $745

  Tuesday ONLY

 $325 $345 $375

  Wednesday ONLY

 $325 $345 $375

  Thursday ONLY

 $325 $345 $375

  Friday Labs ONLY

 $225 $245 $275
 
PLEASE SELECT ONE PROGRAM CHOICE PER DAY:
 
Tues: Women's Health Track
  Emergency Medicine Track
 
Wed: Cardiovascular Track
  Diabetes Track
 
Thurs: Dermatology Track
  Orthopedics/Sports Medicine Track
 
Fri/Labs: Chest X-rays/ Radiology
  Surgical Techniques
  Joint Injections
 
  Check here if you would like printed copies of the Handouts:
 $
     Registration Fees Subtotal:
 $
DISCOUNTS*:

  Bring a Colleague Discount
Name of colleague*:

NOTE: To qualify for this discount, print this completed form and mail or fax to 770–640–1095. Do NOT submit online.
 		$

  Military Discount – Please check here if you are currently Active Duty Military

 $
*If you are eligable for both discounts, please contact the DMGCME Office at 770–640–1022
GRAND TOTAL: $

 
PAYMENT OPTIONS:
*Please complete all fields in this section.

This site is secure for credit card transactions.

Payment Method: (Choose One)

Visa   MasterCard   Discover   American Express  
Please make a selection.

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Billing Zip Code: A value is required.  Invalid entry.

 


*If you press the "Submit" button, and nothing seems to happen, scroll up and look for error messages in red text.


REFUNDS: Written notice of cancellation must be received by April 10, 2013. A $75 administrative fee will be retained.
For a detailed look at the refund policy, please visit DMGCME.com

Mail or Fax Instructions:
If paying by credit card, please be sure to include all credit card information, including credit card number and billing zip code.
Complete form and mail to: DMGCME
1905 Woodstock Road, Suite 2150
Roswell, GA 30075
Complete form and fax to: 770-640-1095
Payment is due with registration form and must be postmarked/submitted by the above dates to qualify for corresponding rate. To avoid duplicate charges, do not mail original registration form if you have already faxed it or submitted it via this webform.
Make checks payable to DMGCME DMG'S Federal Tax ID#: 58-2582200
In accordance with the Americans With Disabilities Act, please notify the DMGCME office if you have any special needs.

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