APMA News - May/June 2017 - 51

PODIATRIC Medical Assistant
REGISTRATION FORM
About Your Information: All correspondence concerning The National
originating from APMA or supplier vendors who purchase our registrant
mailing list will be sent to the address provided below.

Your Information
Name	

First	Name	for	Badge	

ASPMA	Member?		 	Yes		 	No	

PMAC?		 	Yes		 	No

Name	

First	Name	for	Badge	

ASPMA	Member?		 	Yes		 	No	

PMAC?		 	Yes		 	No

Name	

First	Name	for	Badge	

ASPMA	Member?		 	Yes		 	No	

PMAC?		 	Yes		 	No

DPM	Employer	

APMA	Member?		 	Yes		 	No

Address	

	

City/State/Zip	Code

Office	Phone	

Fax	

Email	Address

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:
	

Annual Scientific Meeting Registration Fee

Payment

(Circle appropriate amount)

Total Registration Amount

	 	Each	Assistant

$199

Number	of	assistants	registered	

$199
	

Total $
(Note: Assistants' examination fees must be paid separately
and may not be included in this total.)

Please note:
*		Educational	topics	are	subject	to	change	as	the	program	
schedule	develops.
*	All	registration	fees	must	be	paid	in	advance.	
*		Full	payment	must	be	received	with	your	registration	form,	or	
the	total	must	be	recorded	as	part	of	the	sponsoring	DPM's	
registration.	Registrations	without	complete	payment	will	not	
be	processed.	
*		Registration	for	The	National	includes	educational	sessions	
(unless	otherwise	noted),	exhibit	hall	entry,	and	refreshment	
breaks.	Note:	There	is	a	separate	fee	for	the	examinations	and	
review	courses;	they	are	not	included	in	the	fee	schedule	on	
this	page.	
*		A	confirmation	of	registration	will	be	sent	to	you	by	fax,	mail,	
or	email	within	five	to	10	business	days	after	receipt.	
*	Written	requests	for	registration	refunds	must	be	postmarked	
on	or	before	July	9,	2017.	Registration	fees	are	refunded	less	a	
$50	processing	fee.	All	refunds	will	be	issued	after	the	meeting	
has	occurred.
*		No	refunds	will	be	made	after	July	9,	2017.	Refunds	are	not	
granted	to	no-shows.

$

Payment	type	(check	one):	Registration will not be
processed unless accompanied by full payment.
	Check	enclosed	in	US	dollars	(payable	to	APMA,	Inc.)
	MasterCard			 	VISA			 	American	Express			 	Discover

Credit	Card	Number	(please	print	clearly)	

Expiration	Date

Name	on	Card	(please	print	clearly)
Authorized	Signature		

Date

Day	Phone	of	Cardholder

Mail, email, or fax your completed registration to:
American	Podiatric	Medical	Association,		
Annual	Meeting	Office
9312	Old	Georgetown	Road,	Bethesda,	MD	20814-1621
Fax:	301-530-2752
Email:	membership_ask_apma@apma.org

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	certification	examinations	and	review	courses	
offered	by	ASPMA	in	conjunction	with	The	National.

As	of	3/8/2017

APMA News May/June 2017

51
Table of Contents for the Digital Edition of APMA News - May/June 2017
