Register "*" indicates required fields Attendee InformationAttendee Type* Member Non-Member Applicant PA/ARNP/RN/TECH Resident Fellow Medical Student Name* First M.I. Last Suffix Designation MD DO DFSVS FSVS FACS RPVI PA ARNP RN RVT Practice/Academic Institution Name Academic Title Department Email* Cell Phone*Work Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Attendee ListNew ACCME guidelines require that GVS must receive your permission for your contact information to be included in the onsite attendee list and directory listed in the back of the final program.Do you want to be included in the Onsite Attendee List and the GVS Directory printed in the back of the final program?* Yes No GuestsWill you be attending with a spouse or other guest? Yes No Please enter the name of each guest that will be attending with you.Special AccommodationsDo you or any guest have dietary restrictions or require other special accommodations? Yes No Please list any dietary restrictions or special accommodationsActivitiesWhich events are you interested in? Sporting Clay Golf Tournament Pickleball Round Robin Tennis Round Robin President's Tailgate PickleballHow many adult tickets do you need? Quantity* Price: $30.00 Quantity Please enter the names of each adult participating.*TennisHow many adult tickets do you need? Quantity* Price: $35.00 Quantity Please enter the names of each adult participating.*President's TailgateHow many adult tickets do you need? Quantity* Price: $75.00 Quantity Please enter the names of each adult participating.*Do you plan to bring children under the age of 18?* Yes No How many tickets do you need for children ages 12 to 17? Quantity Price: $50.00 Quantity Children under 3 are no chargeHow many tickets do you need for children under age 12? Quantity Price: $25.00 Quantity Children under 3 are no chargePlease enter the names of all children that will be participating.Sporting ClayHow many sporting clay tickets do you need? Quantity* Price: $100.00 Quantity Please enter the names of each person participating.*Golf TournamentHow many golf tickets do you need? Quantity* Price: $240.00 Quantity Please enter the names of each person participating.*PaymentTotal How would you like to pay?* Credit Card Check Please make checks payable to Georgia Vascular Society, Inc.Credit Card*Card Details Cardholder Name
