Arkansas Academy of Family Physicians
REGISTRATION FORM
AR AFP - 63rd ANNUAL SCIENTIFIC ASSEMBLY
July 28-30, 2010
NAME:___________________________________________________________________________
ADDRESS:________________________________________________________________________
CITY ____________________________________________STATE_________ ZIP_____________
EMAIL:___________________________________________________________________________
TELEPHONE:_________________________SPOUSE\GUEST_____________________________
Please Indicate Syllabus Preference:
Printed Book_____ or USB Drive_____
SCIENTIFIC ASSEMBLY FEES:
Academy Members - $425.00 Student Members - No Charge
Non Members - $475.00 Spouse\Guest - $75.00
Inactive\Life - $125.00 Installation Banquet Only- $45.00
Resident Members - $75.00
ASSEMBLY FEES:
Scientific Assembly Fee (includes Installation Banquet) $___________
Spouse\Guest Fee (see program for included meals/events) $___________
Additional Installation Banquet Ticket Only………….. $___________
ArAFP Foundation Fund – Optional Contribution ….. $___________
*TOTAL ENCLOSED $___________
The following functions are included in assembly registration fees:
Please indicate how many people will be attending-
Welcome Reception – Tuesday Evening………………………………….………_________
Physician Lunch - Wednesday …………….……………………………………_________
Physician Breakfast Meeting – Thursday ……………………………..………_________
Lunch with Exhibitors – Thursday …………………………………… _________
Installation Banquet – Thursday Evening……….……………………………....._________
Breakfast Meeting – Friday………………………………………………………._________
*REGISTRATION AFTER JULY 12th ADD $100.00
*ON SITE REGISTRATION ADD $100.00
_______CHECK ENCLOSED (Payable to AAFP)
CREDIT CARD #_______________________________________________
MAIL, FAX OR PHONE TO:
AAFP,
Fax# (501) 223-2280** Phone (501) 223-2272 ** In State 1-800-592-1093
