Sociedad Mexicana De Oftalmologia

31th PAN-AMERICAN CONGRESS OF OPHTHALMOLOGY August 4 – 8, 2015 … Bogotá, Colombia

REGISTRATION FORM

PLEASE FILL IN THIS FORM WITH BLOCK LETTERS ID PAAO (optional): Degree: MD  PhD  Technician  Nurse 

Name: Last name(s) First Name Middle Initial Address: Street address Apt/Ste. #

City State Zip Code Country

Telephone:  office;  home;  cellular Fax E-mail (BLOCK LETTERS)

Name of Companion(s):

CONGRESS REGISTRATION ALL PRICES IN US DOLLARS

Early Bird Until On SITE Until July REGISTRATION FEE Category February Decembe August 4- 1, 2015 INCLUDES: 28, 2014 r 31, 2014 8, 2015

PAAO Active Member* $200 $250 $350 $400  Admission to all Scientific Sessions Speaker fee $200 $200 $200 $200  Meeting Bag and Final Program Residents / Fellows** $125 $150 $175 $200  Free Access to Exhibition Area Technician/Nurse*** $125 $150 $175 $200  Certificate of Attendance Opening Ceremony & Welcome Reception Non Member $450 $500 $550 $600 

 Free Access to Exhibition Area  Opening Ceremony & Welcome Reception Companions $100 $100 $100 $125  IMPORTANT: the registration fee does NOT include admission to the scientific sessions, Final Program or other congress documentation TOTAL

* PAAO Active member. Ophthalmologist who pays annual membership fee to the PAAO. PLEASE NOTE: If you register as a PAAO Active Member, but are not currently up on your dues, you will be billed for the current-year dues in addition to the registration fee.

** Residents / Fellows: Must show letter from the training Hospital verifying your residence or fellowship at time of registration, otherwise non-member fee will be charged.

*** Technicians and Nurses: Must show a letter from their employer verifying employment status. CANCELLATION & REFUND POLICY: Requests for cancellation and refund must be received in writing. - Until December 31, 2014: full refund less $50 administrative fee per registration - After January 1, 2015 to July 1, 2015: 50% refund - After July 1, 2015: no refund

FORM OF PAYMENT Mark the corresponding box with an X

 Cash  Check payable to: Pan-American Association of Ophthalmology. (US BANKS ONLY)

 Credit card charge: TOTAL AMOUNT USD $ Charge will appear as Pan-American Association of Ophthalmology

Type of credit card:  Visa  Master Card  American Express  Discover Card

Card number: Expiration Date  Security Code  month year Visa and M.C. a 3 digit number found in the back of the card American Express a 4 digit number found in the center right of your card

Name of the card holder Date: Signature of the cardholder

For Information contact: Pan-American Association of Ophthalmology 1301 S. Bowen Road, Suite 450 Arlington, TX 76013 USA Tel.: (817) 275-7553 / Fax: (817) 275-3961 / [email protected] / www.paao.org