2021 Virtual Summit to Sound Registration 2021 Virtual Summit to Sound Registration Date Date Format: MM slash DD slash YYYY Contact InformationName* First Last Credentials (MD, DO, PhD, etc.) Preferred First Name for Badge (If Different than Above)ED Group/HospitalAddress Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code PhoneEmail* E-mail address is required to receive a confirmation/receipt and your e-syllabus. FULL CONFERENCE REGISTRATION*Please select the appropriate registration rate below.Member Physician - $150.00Non-Member Physician - $250.00Allied Health Professional - $100.00Retired - $40.00Resident/Student - $40.00TOTAL $0.00 Payment Type*Credit CardCheckCheck Number*CREDIT CARD American ExpressDiscoverMasterCardVisa Card Number Expiration Date Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Security Code Cardholder Name CANCELLATION POLICY: We must receive written notification of your cancellation. A $50 processing fee will be deducted from the registration refund. No refunds will be issued after May 1, 2020. INQUIRES: Contact the WA/ACEP Office at 206-956-3648 or send emails to firstname.lastname@example.org. Registration Information One registration form per person is required. Please type or print clearly. Your name badge will reflect the information you provide on the registration form. A registration confirmation will be emailed to you.