2021 Fall Conference Registration Registration InformationFirst Name* Last Name* Preferred Name for Badge* Role*MDDONPPAStudentOtherRole - Other* Affiliation* NPI Number* This is used to report CME credit hours attended.Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Reception and Box LunchesWill you be attending the reception on Monday:*YesNoNumber Attending Reception*Please enter a number from 1 to 6.Please indicate whether you would like lunch: Monday Tuesday Wednesday None Will you be attending the Migraine Product Showcase on Tuesday? (No cost to attend)*YesNoWill you attend the Pediatric Cardiac Ultrasound and Workshop on Wednesday morning? (Included in conference registration.)*YesNoRegistration FeesConference Registration* Full Conference Individual Days Registration Type*Physicians - $650Non-Physicians - $550Resident Physicians - $125Days Attending* Monday, October 4 Tuesday, October 5 Wednesday, October 6 Thursday, October 7 Coupon Total $0.00 Pay By* Credit Card Check Credit CardCard Details Cardholder Name For more information, or to submit your check, contact: Liz Taylor Asst. to Executive Director North Carolina College of Emergency Physicians PO Box 1038 Wake Forest, NC 27588 email@example.com **Please note that no printed copies of the course syllabus will be provided at the conference. Lecture materials will be provided in an electronic format prior to or at the conference. Please consider bringing a laptop or tablet if you would like to view the presentations during the lectures. PLEASE NOTE: YOU WILL NOT RECEIVE A CME CERTIFICATE UNLESS YOU COMPLETE THE OVERALL ACTIVITY EVALUATION.