2013 Registration

Practice Plan Registration DOWNLOAD FORM

CONTACT INFORMATION

* Required

*First/Given Name:

*Last/Family Name:

*Degree:

*Address:

*City:

*State/Province:

*Zip code:

*Country:

*Phone:

Fax:

*E-mail:

Year of Birth:

Year of Medical
School Graduation:

State of Practice:

Subspecialty*:

Cataract surgery Contact lenses Cornea/External disease General ophthalmology Glaucoma Retina	Neurosciences Oculoplastics Optics Pediatrics/Strabismus Refractive surgery
If you are registering for the Hawaiian Eye 2013 Comprehensive Ophthalmologist Program*, click here.

*How did you hear about the meeting? Multiple selections allowed	Ocular Surgery News Print Advertisement OSN SuperSite and/or News Wire OSN Exhibit Booth E-mail Letter Brochure Flyer Phone Word of Mouth Internet Search Other
Priority Code Please enter the priority code found on the lower right-hand corner of your brochure registration form (inside back cover) or other marketing materials. Codes contain 3 numbers, a dash, and then more number(s).

*REGISTRATION

Registration includes admission to all program sessions, workshops, breakfast and lunch seminars, the exhibit hall, and the evening receptiobn and special evnts. Note: Retina registration is valid for physicians only. This program offers AMA PRA Category 1 Credits™.

E. Early Bird Registration (Register early and save $155!)........US $1195 + 4.16% Hawaii Excise Tax = $1244.71

EE. Standard Registration........US $1350 + 4.16% Hawaii Excise Tax = $1406.16

ERF. Resident/Fellow(must submit letter of verification)........US $740 + 4.16% Hawaii Excise Tax = $770.78

CME Activity Request
	Yes, I would like the opportunity to earn CME credits through activities jointly sponsored by Ocular Surgery News^® and Vindico Medical Education.

Exhibitor Registration
All exhibiting companies must register their attendees as "exhibitors." Contact Donna Rosenstock for exhibitor registration details by e-mailing drosenstock@slackinc.com or by calling 856-848-1000, ext. 257.

*BILLING ADDRESS
(check if the same as Contact Information at top of page)

*Accountholder's Name:
*Statement Mailing Address:
*City:
*State/Province:
*Country:
*Postal Code:

I understand and agree to the following:
Requests for meeting registration refunds must be submitted in writing prior to January 3, 2013. There will be a $200 cancellation fee applied per person for each cancelled physician registrant, and $100 cancellation fee applied per person for each cancelled nurse/allied health or administrator registrant. After January 3, 2013, no refund will be granted.

Meeting registration for Retina 2013 does not guarantee accommodations at participating hotels.

Dress code for this meeting is resort casual.

Contact Us

Mailing Address:	Meeting Registration 6900 Grove Road Thorofare, NJ 08086-9447

Toll-Free Phone:	877-307-5225, ext. 219 or 476

International Phone:	+1-856-848-1000, ext. 219 or 476

Fax:	856-251-0278

E-mail:	meetingregistration@SLACKInc.com

Office Hours:	9:00 AM - 5:00 PM, Monday - Friday, EST

For more information, contact Meeting Registration by e-mail: meetingregistration@SLACKInc.com

Federal ID # 27-4318741

Cancellations: Requests for meeting registration refunds must be submitted in writing prior to January 3, 2013. There will be a $200 cancellation fee applied per person for each cancelled physician registrant, and $100 cancellation fee applied per person for each cancelled nurse/allied health or administrator registrant. After January 3, 2013, no refund will be granted.

ADA Compliance: In compliance with the Americans with Disabilities Act of 1990, we will make all reasonable efforts to accommodate persons with disabilities. Please call with your requests.