Register Attendee InformationAttendee Type* Member Non-Member Applicant PA/ARNP/RN/TECH Resident/Fellow/Medical Student Fellow Medical Student Name* First M.I. Last Suffix Designation MD DO FSVS FACS RPVI PA ARNP RN RVT Practice/Academic Institution Name Academic Title Department Email* Cell PhoneWork Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 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 President's Tailgate President's TailgateHow many adult tickets do you need?* 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 4 to 17? 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?* Price: $100.00 Quantity: Please enter the names of each person participating.*Golf TournamentHow many golf tickets do you need?* Price: $150.00 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
