Registration PDF CAOG Meeting Registration Form Date:* MM slash DD slash YYYY Name:* First Middle Last M.D./D.O./Other Badge Name: ACOG # Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone:*Email:* Select Your Date/Events and # of PeopleAll Costs Covered in Registration FeeWednesday, October 16, 2024 | 6:00 – 9:00 p.m. (Welcome Reception/Buffet Style)Select # of People0123456Thursday, October 17, 2024 | 9:30 a.m. – 1:00 p.m. (Partners/Guests Only) Continental Breakfast/Dali ExhibitSelect # of People0123456Friday, October 18, 2024 | 6:00 – 10:00 p.m. (Reception/Dinner/Awards/Dance)Select # of People0123456 Registration FeeCAOG Member $700 Per PersonSelect # of People1 ($700)2 ($1,400)3 ($2,100)4 ($2,800)5 ($3,500)6 ($4,200)CAOG Adjunct $550 Per PersonSelect # of People1 ($550)2 ($1,100)3 ($1,650)4 ($2,200)5 ($2,750)6 ($3,300)CAOG Life Member $600 Per PersonSelect # of People1 ($600)2 ($1,200)3 ($1,800)4 ($2,400)5 ($3,000)6 ($3,600)Residents/Nurses $500 Per PersonSelect # of People1 ($500)2 ($1,000)3 ($1,500)4 ($2,000)5 ($2,500)6 ($3,000)Non-Member (MD/DO) $800 Per PersonSelect # of People1 ($800)2 ($1,600)3 ($2,400)4 ($3,200)5 ($4,000)6 ($4,800)Partners/Guests $300 Per PersonSelect # of People1 ($300)2 ($600)3 ($900)4 ($1,200)5 ($1,500)6 ($1,800)Students $300 Per PersonSelect # of People1 ($300)2 ($600)3 ($900)4 ($1,200)5 ($1,500)6 ($1,800)Total (USD) $0.00 Indiana/Local NonMember CME only daily fee $100 each.Each day is $100 select what days you want and the number of people attending on that specific day.Thursday (Includes Science, Breakfast, Break) $100 Per DaySelect # of People1 ($100)2 ($200)3 ($300)4 ($400)5 ($500)Friday (Includes Science, Breakfast, Break) $100 Per DaySelect # of People1 ($100)2 ($200)3 ($300)4 ($400)5 ($500)Saturday (Includes Science, Breakfast, Break) $100 Per DaySelect # of People1 ($100)2 ($200)3 ($300)4 ($400)5 ($500)Total (USD) $0.00 Partners/Guests Registration FeeThe $300 partner/guest registration fee includes Welcome Reception/Buffet (Wednesday), Partner/Guest Event (Thursday) with Continental Breakfast followed by transportation to and from the Dali Alive Art Exhibit and the Reception/Dinner/Award/Dance (Friday). Registered partners/guests will receive a name badge. Children 12 years and under are not required to pay a fee but must be registered.Names of Partners/Guests (one name per row, click + to add row)Names of Children 12 and Under – No charge (One name per row, click + to add row)Total (USD) $0.00 Payment Information: Payment must be received in full to process your registration. Payment can only be in the form of a check or credit card. The link to pay with a credit card will be shown below (If you have multiple people, select price option, enter name and add to cart. Then repeat the process.) If you are paying via check, insert the check number. (Address to ship is visible below) For questions regarding registration please call 701-838-8323 (Rochelle).Total (USD) $0.00 PaymentsCheck Number Cut-Off Date: Your registration form must be received by CAOG no later than Friday, September 6, 2024. Please call if you experience any last minute problems. Cancellation Policy: Written cancellation must be received prior to Friday, September 13, 2024. A $50 administrative fee will be assessed. No refunds will be issued after the September 13, 2024 cancellation date. Confirmation: Registrants will receive written confirmation with final details 3 weeks prior to the meeting. To register by mail return completed form and payment to: Rochelle Hickel, CAOG Executive Director P.O. Box 3010 Minot, ND 58702-3010 To register by fax call: 701-852-8733 *Remember to please check with the bellman for complimentary luggage storage on the day you depart so you don’t need to leave the meeting early!CAPTCHA
