94th Annual Meeting of the Endocrine Society


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94th Annual Meeting of the Endocrine Society

  1. 1. ENDO 2012 REGISTRATION fORm (page 1 of 2) Early Registration: Regular Registration: Late/Onsite Registration: Promo code________________ by may 1, 2012 may 2-may 30, 2012 may 31-June 26, 2012 Society ID# ________________ A. ATTENDEE INfORmATION (Please print all information.)q 1 Dr q 2 Mr q 3 Ms q 4 Prof q Recently applied for membershipLAST NAME FIRST NAME MIACADEMIC CREDENTIALS q 1 DO q 2 MD q 3 MD, PhD q 4 NP q 5 PA q 6 PhD q 7 RD q 8 RN q 9 RPH/PharmD q 10 OtherPROFESSIONAL TITLECOMPANY/INSTITUTION q Home q BusinessDEPARTMENT /DIVISIONMAILING ADDRESS STREETCITY STATE COUNTRY ZIP/POSTAL CODETELEPHONE (DAY): COUNTRY CODE/CITY CODE/NUMBER FAX: COUNTRY CODE/CITY CODE/NUMBERE-MAIL NPI NUMBERALL INFORMATION IN SECTION A MUST BE COMPLETED IN ORDER TO REGISTER. IF INFORMATION IS NOT APPLICABLE PLEASE INDICATE N/A IN THE SPACE PROVIDED.B. PROfESSIONAL INfORmATION (Please print all information.)Indicate your area What is your primary What is your What is your What is your How did you learnof training, expertise or professional role? specialty area? professional setting? training status? about this meeting?interest within q D-Researcher (Basic) q K-Adult Endocrinology q P-Academic Institution q W-Student q AA-Endocrine Societyendocrinology Email q E-Researcher (Clinical) q L-Internal Medicine q Q-Hospital/Clinic q X-Clinical Fellowq A-Basic Research q BB-Endocrine Society q F-Educator/Teacher q M-Pediatric Endocrinology q R-Government/Military q Y-Post-doctoralq B-Clinical Research Webpage q G-Nurse/Healthcare q N-Research q S-Pharmaceutical/Industry Fellowq C-Clinical Practice Professional q CC-Mailing q O-Other (please specify): q T-Private Practice q Z-Completed q H-Clinical Practitioner Training q DD-Previous Attendance q U-Private Research q I-Trainee/Fellow ––––––––––––––––––––––––– Firm/Institute q EE-Colleague q J-Retired or Other q FF-Journal q V-Other (please specify): Advertisement ––––––––––––––––––––––––– ––––––––––––––––––––––––– q GG-Other (please specify):Have you ever attended ENDO before? q Yes q No –––––––––––––––––––––––––C. REGISTRATION CATEGORIES (Please print all information.) *Membership rates valid with paid 2012 membership duesPREmIum REGISTRATION PACkAGE: Includes ENDO Registration, Session Library and Clinical MTP Handout Book.Best Value for Clinical Attendees. Save up to $150 on the ENDO 2012 Session Library, and get a free Clinical meet the Professor Handout Book. Early: by may 1 Regular: may 2–may 30 Late/Onsite: may 31–June 261. member q $560 q $710 q $7802. Non-member q $1,150 q $1,295 q $1,3703. In-Training member q $345 q $445 q $4704. RN (including ENS members) or PA or NP q $460 q $610 q $680TAkE ENDO 2012 The ENDO 2012 Session Library features more than 100 hours of clinical and translational content from ENDO, available online and on DVD-ROm. The Session Library is available only with Premium Package Registration now through June 22. Register for theHOmE WITH YOu! Premium Package, and reserve the best rate for the ENDO 2012 Session Library ($125 for members and $175 for non-members) and a complimentary mTP Handout Book. On-site prices for the Session Library increase to $200 for member, $275 for Non-mem- bers & $150 for In-Training members.STANDARD REGISTRATION PACkAGE: Includes ENDO Registration Only. DOES NOT Include Session Library or Clinical MTP Handout Book Early: by may 1 Regular: may 2–may 30 may 31–June 265. member q $435 q $585 q $6556. Non-member q $975 q $1,120 q $1,1957. In-Training member q $220 q $320 q $3458. In-Training Non-member q $400 q $515 q $5409. RN (including ENS members) or PA or NP q $335 q $485 q $55510. member or ENS member One Day q $250 q $325 q $375 Please check which day q Saturday q Sunday q Monday q Tuesday11. Non-member One Day q $340 q $425 q $475 Please check which day q Saturday q Sunday q Monday q Tuesday12. Emeritus member q Free13. Complimentary q Free14. Guest q $100 GUEST LAST NAME, FIRST NAME (PLEASE PRINT)
  2. 2. (page 2 of 2)LAST NAME FIRST NAME MI D. ENDOCRINE NuRSES SOCIETY PROGRAm1. Endocrine Nurses Society: Symposium, Business Meeting, q Free 2. Non-Member Attending ENS Luncheon: Sunday, June 24 q $15 Luncheon, Poster Session & Reception: Sunday, June 24 *see criteria *(Primary professional role must be Nurse or Allied Health Professional to attend) E. OTHER EVENTS, OPTIONAL fEES & SPECIAL ACTIVITIES (Please print all information.)3. Diabetes Diagnosis & management 2012: friday, June 22 12. New! Career Development Workshop Evening Session: Member or ENS Member q $55 How to Write a Successful Career Development Award, Non-Member q $85 monday, June 25 q $30 In-Training (Member or Non-Member) q $45 13. New! Career Development Workshop Evening Session:4. Endocrine Trainee Day, Class of 2012 (only open to In-Training members) Writing a Successful R01 or Other Independent Research Grant q $125 Application- Tips for the mid-Career Investigator monday, June 25 q $305. Thyroid Sonography Workshop Beginner: friday, June 22 Member or ENS Member q $375 Non-Member q $445 15. Comp Student Trainee Day (by invitation only) q Free In-Training (Member or Non-Member) q $260 16. Shuttle Pass (please read information below) q $506. Thyroid Sonography Workshop Advanced: friday, June 22 Member or ENS Member q $405 Quantity _________ Non-Member q $475 In-Training (Member or Non-Member) q $285 17. Hormones and Cancer forum 9:00 am – 6:00 pm: friday, June 22 Member or ENS Member q $1157. Clinical mTP Handout Book Non-Member q $165 (included with Premium Package Registration) In-Training (Member or Non-Member) q $45 Member or ENS Member q $25 Non-Member q $35 18. forum on GPCRs 9:00 am – 6:00 pm: friday, June 22 Member or ENS Member q $1158. Adrenal mOC Self Assessment module Session: Saturday, June 23 Non-Member q $165 Member or ENS Member q $210 In-Training (Member or Non-Member) q $45 Non-Member q $3359. Women in Endocrinology Dinner: Saturday, June 23 q $70 ImPORTANT ENDO SHuTTLE SERVICE INfORmATION: There will be -limited- shuttle service at ENDO 2012. Please see hotel map/description for list of hotels on the shuttle route. The shuttle service is COMPLIMENTARY for attendees who re- Quantity _________ serve their room through ENDO’s official housing company, Experient. One shuttle pass will10. Trainee Reception: friday, June 22 be issued to each adult registered to a room (children under 16 years don’t require a shuttle (only open to In-Training members & Non-members) q Free pass); upon check-in at their hotel, enabling them to ride the ENDO shuttle at no additional cost. Rooms reserved outside the official ENDO block, not booked through Experient, will be required to purchase a $50 shuttle pass for each person to ride the shuttle.11. minority mentoring Reception: Sunday, June 24 q Free Shuttle passes will be available for purchase in advance through the registration 11a. mentor Registration (deadline April 12, 2012) q Free site/form or onsite at the meeting. The pass is valid for the duration of the meeting. f. OTHER INfORmATION (Please print all information.)q Traveling from outside the U.S. or Canada and will require a Letter of Invitation for travel and visa processing. PASSPORT NUMBER (REQUIRED)q Require special assistance. (Please attach description of needs).q Provide my e-mail address to exhibitors.Emergency contact (required):NAME DAY TELEPHONE EVENING TELEPHONE G. PAYmENT INfORmATION (Please print all information.)TOTAL SECTIONS C $__________ + D $_____________ + E $________________ = Total Amount Due $_________________________ 0 0 0 0Full payment must accompany your registration form. Enclose your check (payable to The Endocrine Society in U.S. funds only), or complete the credit cardinformation below. Purchase orders are not accepted as payment for registration fees.q Check (enclosed) q VISA q MasterCard q American Express /CARD NUMBER EXPIRATION DATE (MM/YY)NAME OF CARDHOLDER (please print)BILLING ADDRESS BILLING ZIP/POSTAL CODESIGNATURE Your signature authorizes your credit card to be charged for the total payment above. The Endocrine Society reserves the right to charge the correct amount if different from the total payment listed above. The signer above has read and agrees to the cancellation policy.z H. CHANGES OR CANCELLATION POLICYCANCELLATION POLICY Cancellations must be made in writing by may 30, 2012 for full refund, minus $50 USD administrative fee. Requests between may31-June 22, 2012, will be refunded 50% of their registration fee. No refunds issued after June 22, 2012. Requests for changing Premium Package will not behonored after may 30, 2012.fAX registration form with credit card information no later than may 30, 2012, to 301.694.5124. If faxing, do not mail or you will be double-charged.mAIL registration form with full payment no later than may 30, 2012 to: ENDO 2012 Registrar, c/o Experient, P.O. Box 4088, Frederick, MD 21705-4088ONLINE register with credit card information at www.endo-society.org/endo until June 26, 2012.WIRE TRANSfERS contact ENDO 2012 Registrar at endo@experient-inc.com; phone 866.229.2386 (toll free) or 301.694.5243; fax 301.694.5124