APMA News - March/April 2019 - 33

PODIATRIC
MEDICAL ASSISTANT
REGISTRATION FORM
The registration on this page is for assistants attending The National
only. Please see the reverse side of this form for a separate registration,
schedule, and fee for the review courses and certification examinations
offered by ASPMA in conjunction with The National.

YOUR INFORMATION
Name

First Name for Badge

ASPMA Member?

Yes

PMAC?

Yes

Name

First Name for Badge

ASPMA Member?

Yes

PMAC?

Yes

Name

First Name for Badge

ASPMA Member?

Yes

PMAC?

Yes

DPM Employer

APMA Member?

Yes

Address

City/State/Zip Code

Office Phone

Fax

Email Address

ANNUAL SCIENTIFIC MEETING
REGISTRATION FEE

PAYMENT

After 3/1/19
Each Assistant

$199

TOTAL REGISTRATION AMOUNT

Payment type (check one): Registration will not be
processed unless accompanied by full payment.

Number of assistants registered

TOTAL

Check enclosed in US dollars (payable to APMA, Inc.)
MasterCard VISA American Express Discover

(Note: Assistants' examination fees must be paid separately
and may not be included in this total.)
PLEASE
PLEASE NOTE:
NOTE:
* Educational
* Educational topics
topics are
are subject
subject to
to change
change as
as the
the program
program schedule
schedule
develops.
develops.
* All
* All registration
registration fees
fees must
must be
be paid
paid in
in advance.
advance.
* Full
* Full payment
payment must
must be
be received
received with
with your
your registration
registration form,
form, or
or the
the total
total
must
must be
be recorded
recorded as
as part
part of
of the
the sponsoring
sponsoring DPM's
DPM's registration.
registration.
Registrations
Registrations without
without complete
complete payment
payment will
will not
not be
be processed.
processed.
* Registration
* Registration for
for The
The National
National includes
includes educational
educational sessions
sessions (unless
(unless
otherwise
otherwise noted),
noted), exhibit
exhibit hall
hall entry,
entry, and
and refreshment
refreshment breaks.
breaks. Note:
Note: There
There
is
is a
a separate
separate fee
fee for
for the
the examinations
examinations and
and review
review courses;
courses; they
they are
are not
not
included
included in
in the
the fee
fee schedule
schedule on
on this
this page.
page.
* A
* A confirmation
confirmation of
of registration
registration will
will be
be sent
sent to
to you
you by
by fax,
fax, mail,
mail, or
or email
email
within
within five
five to
to 10
10 business
business days
days after
after receipt.
receipt.
* Written
* Written requests
requests for
for registration
registration refunds
refunds must
must be
be postmarked
postmarked on
on or
or
before
before June
June 17,
17, 2019.
2019. Registration
Registration fees
fees are
are refunded
refunded less
less a
a $50
$50
processing
processing fee.
fee. All
All refunds
refunds will
will be
be issued
issued after
after the
the meeting
meeting has
has occurred.
occurred.
* No
* No refunds
refunds will
will be
be made
made after
after June
June 17,
17, 2019.
2019. Refunds
Refunds are
are not
not granted
granted to
to
no-shows.
no-shows.

Credit Card Number (please
(please print
print clearly)
clearly)
Expiration Date Security Code
Name on Card (please
(please print
print clearly)
clearly)
Authorized Signature Date
Day Phone of Cardholder

ADDITIONAL INFORMATION
Per the Americans With Disabilities Act of 1990, check here
if you have a disability and may require accommodations to
participate fully. Please describe:

Mail, email, or fax your completed registration to: American Podiatric Medical Association, Annual Meeting Office
9312 Old Georgetown Road, Bethesda, MD 20814-1621 | Fax: 301-530-275 | Email: membership_ask_apma@apma.org
As of 2/22/2019
PDF_PRELIM As of
PDF_PRELIM As
of 2/22/2019
2/22/2019

APMA News March/April 2019

APMA News - March/April 2019

Table of Contents for the Digital Edition of APMA News - March/April 2019