Annual Conference Online Registration 2019 Annual Event RegistrationThis 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 200, 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*Please select your membership categorySociety Member ($50)Physician Non-Society Member ($300)Other Healthcare Professional Non-Society Member ($175)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 MealYesSelect Registration Level:*Select productSociety Member ($50)Physician Non-Society Member ($300)Other Healthcare Professional Non-Society Member ($175)QuantityInclude NCSG Dues:Select productPhysician 1 year = $150Physician 3 years = $425Allied 1 year = $100Allied 3 years = $275QuantityAfter 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, 2019. If your employer is paying your registration, please send the form via mail or fax to: NCSG, 1112 Harding Place, Suite 200, 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.MailFaxEmailOnLineWord Verification:SubmitReset
