APMA News - January/February 2018 - 33

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
(Circle appropriate amount)

	Each	Assistant

Until 3/2/18

After 3/2/18

$99

$199

Total Registration Amount

$

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

Number	of	assistants	registered	
Total

Payment

$

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

Credit	Card	Number	(please print clearly)	

Expiration	Date

Name	on	Card	(please print clearly)
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	June	18,	2018.	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	June	18,	2018.	Refunds	are	not	granted	
to	no-shows.

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	review	courses	and	certification	examinations	offered	by	ASPMA	in	
conjunction	with	The	National.
As of 1/12/2018

	Prelim	Pgm	1			As	of	1/12/2018

APMA News January/February 2018

33
Table of Contents for the Digital Edition of APMA News - January/February 2018
