Annual Conference Fellows Online Registration 2019 Annual Event Registration - FellowsPlease note: Fellows pay no registration fee. NCSG will pay for Friday and Saturday nights stay for you and guest.If you prefer to register with a DPF form, please print the registration form, fill it in and send to: NCSG, 1112 Harding Place, Suite 200, Charlotte NC 28204. You may fax your form to: 704.376.3173.If you prefer to email your registration form, please send your information to ssmith@meckmed.org.SalutationPlease SelectDr.Mr.Ms.Mrs.Name:* First Last Degree(s) (e.g. MD, PharmD, MS, BS)Clinical SpecialtyHome Address: Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip CodeHome CountyHome or Mobile Phone: Area Code - Phone Number EmployerJob titleDepartmentWork Address: Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip CodeWork Phone: Area Code - Phone Number Work Fax: Area Code - Phone Number Work E-mail:By providing your phone, fax, and email address, you have granted permission for us to communicate with you via the information indicated. Vegetarian MealYesI will be staying: Friday NightSaturday NightI will have a guest with me, name of::I/we will be attending the Fellows Reception on Saturday night:YesNoYour registration information will be emailed to the NCSG office. If you have questions, please contact Sandi Buchanan at 704.376.3688 or ssmith@meckmed.org. Word Verification:SubmitReset