ANNUAL SCIENTIFIC MEETING REGISTRATION Check appropriate amount. EARLY-BIRD RATE (Until March 29) APMA Member APMA Life Member DPM (Non-APMA Member) Health-Care Professional APMA Student/Resident/Fellow Member APMA Member Young Physician EMERGENCY CONTACT Name Telephone Email 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: $399 $299 $949 $949 Complimentary $299 $399 PAYMENT REGISTRATION FEE $ Registration will not be processed unless accompanied by full payment. Payment type (check one): Check enclosed in US dollars (payable to APMA, Inc.) MasterCard VISA American Express Discover Credit Card Number Expiration Date IMPORTANT! Please check the box below to indicate your agreement to APMA's meeting policies. Your registration will not be processed if this box is not checked. By registering for this meeting, I agree to all of APMA's registration and meeting policies listed at www.apma.org/TheNationalPolicies. Name on Card Authorized Signature Date Day Phone of Cardholder $399 REGULAR RATE (March 30-August 6) $649 $399 $949 $949 ON-SITE RATE (After August 6) $849 $399 $949 $949 Security Code MAIL, EMAIL, OR FAX YOUR COMPLETED REGISTRATION TO: American Podiatric Medical Association 11400 Rockville Pike, Suite 220, Rockville, MD 20852 Fax: 301-530-2752 Email: registration@apma.orghttp://www.apma.org/TheNationalPolicies