CONFERENCE REGISTRATION …

   CONFERENCE REGISTRATION
                                                                                                                             Michigan Chapter ACC
                                                                                        ANNIVERSARY                          September 26-28, 2008
1. Please register me for the conference.
                                                                                        CONFERENCE                           Grand Traverse Resort
Today's Date:

First Name:                                                   Middle Initial:      Last Name:

Company/Institution/Practice:

Designation:      MD      DO        PhD   PA    RN   NP       PharmD      Other (please specify)

Address:

City:                                                                               State             Zip                         Country

Email:                                                               Telephone:

ACC member:        Yes     No If yes, enter member number


2. I plan to attend the following.                                                 Spouses/guests are invited to attend the Welcome Reception
                                                                                   (complimentary) and Lunch with the President ($25 ticket).
   FRIDAY              Cardiac Care Associate (CCA) Session
                                                                                   Determine amount due by checking all that apply:
                       Oral Case Competition
                                                                                          ACC member physician                                   195
                       Poster Competition Finals
                                                                                          Non-member physician                                   275
                       PAD Symposium
                                                                                          ACC Cardiac Care Associate member                       95
                       Interventional Cardiology at the Crossroads
                                                                                          Non-member Allied Health Professional
                       Welcome Reception
                                                                                            (RN, NP, PA, etc.)                                   150
   SATURDAY            Continental Breakfast                                              Cardiology Fellow in Training                      waived
                       General Scientific Session                                         Internal Medicine Resident                         waived
                       Lunch with the President                                           Spouse/guest ticket for Saturday
            Dietary Restrictions:                                                           Lunch with the President                   $25 X
                                                                                                                               (indicate # of tickets)

   SUNDAY              Continental Breakfast                                              Kid's Night (during Welcome Reception) $25 X
                       General Scientific Session                                                                              (indicate # of tickets)


                                                                                      Amount due $
3. Please register my spouse/guest.
                                                                                   7. Payment
Name:
                                                                                          My check (payable to Michigan Chapter ACC) is enclosed.
4. My spouse/guest will attend the following.                                             Please charge my credit card:        VISA       MC        Am Ex
         Welcome Reception
         Lunch with the President ($25)                                               Name on card (print clearly)
            Dietary Restrictions:                                                     Card number                                              Exp. Date
                                                                                   Cancellations: Full refund is made when written cancellation is emailed
5. My child(ren) will attend Kid's Night during the                                (dmsdiane@concentric.net) or faxed (517-663-5245) by Friday, September
                                                                                   23. Fees will not be refunded for no-shows. In the unlikely event that the
   Welcome Reception.                                                              program is cancelled, the Chapter is responsible only for full refund of the
Kid's Night offers age-appropriate food and activities for children ages           registration fee, not for transportation or hotel accommodations.
3-12 during the Welcome Reception. The cost is $25 per child.
                                                                                   8. Return form to:
Name                                                      Age
                                                                                        MCACC 20th Anniversary Conference 2008
Name                                                      Age                           620 Hall Street
                                                                                        Eaton Rapids, MI 48827
Name                                                      Age                           Fax: 517-663-5245
                                                                                   *Faxed registration forms are accepted and encouraged to reserve a space at
6. Tuition                                                                          the conference. Payment may follow in the mail if necessary.
Tuition includes all conference and preconference sessions, CME/CE                 *Confirmation will be mailed to the address entered in #1 above.
credits, syllabus, two continental breakfasts, Welcome Reception, and
Lunch with the President on Saturday. Tuition also includes a Box
Lunch for those attending the CCA Session on Friday.