GNS - Fall Meeting Registration Form

Please fill out the following information in order to begin registration.

Note to Office Managers: If you are registering more than one physician, please enter all the names in the name field.

Registration Fees:

Member Rate - $245/physician

Non-Member Rate - $295/physician

Residents - $50

Number of Registrations:

Name(s) of Attendee(s):

Contact Email:

Practice Name:

Address 1:

Address 2:

City: State: Zip:

Contact Phone: Fax:

Lunch is included in your registration. Number of lunches:

I am paying with credit card. The name on the card is

NOTE - You must continue through the next few pages to complete payment and registration.

I am paying with check.

NOTE - Once you hit submit, you are finished with registration. You do not need to progress to payment screens.

Please send check with names of the registrants in the "Memo" field to:

GNS

c/o Meeting Registration

6134 Poplar Bluff Circle, Suite 101

Norcross, GA 30092

Before you submit, please verify that all information is correct!