GSMA Annual Convention
& Scientific Assembly
combined with NMA Region III


Mail-In/Fax Registration Form*

 

Hotel Accommodations

Register Online to receive special rates at the Omni Resort

or

Reservations can be made by calling Omni central reservation 1-800-843-6664
The group block code is 060714GASTATEME.

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Advance Registation ends May 31, 2014 (10% discount).
After this date all registration must take place on site.

Information:
* First Name
 
* Last Name
 
* E-mail Address
 
* Address
(CME Certificate will be mailed to this address)
 
* City
 
* State
 
* Zip Code
 
* Telephone
 
Fax
 
Registering As:
Registering As:
 
Member
$150.00 $135.00
2014 GSMA membership must be paid to qualify for this rate.
Non-Member Physician
$483.50 $435.00
 
New Member
$710.00 $639.50
 
NMA & Other Affiliate Medical Society Member
$150.00 $135.00
Registrant must show proof of current membership in NMA or Affiliate Medical Society to be eligible for discounted rate
 
 
 
Events/Activities:
Please indicate number of persons attending
June 11:
 
Welcoming Reception (@ $0.00 No Charge)
 
Golf Tournament (@$100 - Participants MUST pre-register)
Tennis Tournament (@$50.00 - Participants MUST pre-register for tournament)
   
June 12:
 
Awards Dinner/Dance (@$65.00)
   
June 13:
 
Family Luncheon: Adult Ticket (@$35.00)
Family Luncheon: Child Ticket (@$15.00)
Additional Comments