Annual Conference Online Registration

2021 Annual Event Registration

This registration form offers PayPal payment at the end of the form. When you press Submit you will be taken to the PayPal payment page.

If you prefer to send a check or mail your credit card info, please print the registration form, fill it in and send your form and payment to: NCSG, 1112 Harding Place, Suite 100, Charlotte NC 28204.

You may fax your form with credit card info to: 704.376.3173.

If you prefer to email your registration form with your credit card information, please note this is not a secure email address and you are taking a risk by sending your information.

Membership Category*

Salutation

Name:*

First

Last

Degree(s) (e.g. MD, PharmD, MS, BS)

Clinical Specialty

Home Address:

Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip Code

Home County

Home or Mobile Phone:

Area Code

Phone Number

Employer

Job title

Department

Work Address:

Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip Code

Work 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.

Select Registration Level:*

Quantity

Include NCSG Dues:

Quantity

After you press the Submit button, you will be taken to PayPal for payment. Your registration information will be emailed to the NCSG office. If you prefer to mail a check or fax your credit card, please indicate which and you may close the PayPal page.

No Refunds after January 25, 2021. If your employer is paying your registration, please send the form via mail or fax to: NCSG, 1112 Harding Place, Suite 100, Charlotte NC 28204 - fax: 704.376.3173.

If you have questions, please contact Sandi Buchanan at 704.376.3688 or ssmith@meckmed.org.

I will be mailing/faxing payment.

Mail

Fax

OnLine