ACMS Registration Form
REGISTER ONLINE WITH A CREDIT CARD! Go to: http://www.mohscollege.org/annualmeeting/registration Early Registration Deadline: February 15, 2021 @ 11:59 pm PST $50 additional fee for ACMS registrations after this date through April 12, 2021 (not valid if received after April 12, 2021)
2021 53 RD ANNUAL MEETING MAY 6–9
Please print clearly. A separate form must be completed for each registrant
Name___________________________________________________________________________________________________________________________
Address__________________________________________________________________________________________________________________________
City___________________________________________________ State/Region_____________ ZIP Code ___________Country___________________________
Phone_________________________________________________ Fax_______________________________________________________________________
Email____________________________________________________________________________________________________________________________ Indicate how you would like your first name to appear on your badge: ________________________________________________________________________________________________________________________________
SPECIAL ACCOMMODATIONS Yes, I (the registrant) require an auxiliary aid or service identified in the Americans with Disabilities Act.
Explain: __________________________________________________________________________________________________________________________ If you have a religious or food allergy-related dietary need, please check the appropriate box below. Vegetarian options will be available at all functions. Please do not include food preferences. Yes, I (the registrant) require specially-prepared food at group functions: Kosher Halal Food Allergy/Other Other: ___________________________________________________________________________________________________________________________
REGISTRATION CATEGORIES AND FEES (NOTE: The registration fee does not include admission to Morning Mini-Sessions. Registrants must sign up for these sessions separately and pay the extra fee for each Morning Mini.)
Early Regular Registration, On or before February 15
Regular Registration February 16- April 12
ACMS Life Members
FREE
FREE
ACMS Fellow, Associate and International Affiliate Members; International Affiliate and Associate Applicants Current Fellows-in-Training (Physicians must be currently participating in an approved fellowship training program in Micrographic Surgery and Dermatologic Oncology/Mohs Surgery.) Dermatology Residents (Physicians must be currently participating in an approved residency and must submit a letter of verification indicating the type of program in which they are enrolled from the program chair with their registration form.)
$800.00
$850.00
$150.00
$150.00
$150.00
$150.00
Non-Member Physicians (A letter of sponsorship from a member of the ACMS must accompany the registration form.)
$1,500.00
$1,600.00
Mohs Surgical Assistants (Surgical assistants employed by an ACMS member may attend scientific sessions, except for Morning Mini- Sessions. Surgical assistants must submit a letter of verification from their physician with their registration form.)
$650.00
$700.00
Guest For 2021, Guest Registration is not offered.
N/A
N/A
Registration Fee Total
$
$
27
2021 ACMS & ASMH Annual Meetings Hyatt Regency Seattle, Seattle, WA • Thursday, May 6 – Sunday, May 9, 2021
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