REGISTRATION FORM - North American Burn Society (NABS)

North American Burn Society
34th Annual Meeting
Jackson Hole, WY
January 16-23, 2016
REGISTRATION FORM
I will be attending the 2016 annual NABS meeting.
_______ I will not be attending the 2016 annual NABS meeting
_______ Please remove my name from the NABS roster
I would like help finding a roommate to share lodging expenses.
All active members in attendance are expected to present a paper at the annual meeting. Emeritus and new members attending for the
first time are encouraged, but not required, to present. Please register online by October 1, 2015 and submit title/abstract on line
by no later than October 1, 2015.
Presentation Title:
Days I will be attending:
Company Name:
Attendee Name:
Title:
Mailing address:
City:
State:
Zip:
Contact Name (if different from above):
Phone:
Email:
Enclosed are my dues and/or registration fees (US):
New member application fee
$35.00
_________________
Bronze level
$750.00
_________________
Silver level
$1000.00
_________________
Gold level
$1250.00
_________________
Platinum level
$1750.00
_________________
Diamond level
> $2000.00
_________________
Physician Members (MD’s, DO’s)
$250.00
_________________
Members (non-physicians)
$175.00
_________________
Non-members
$250.00
_________________
2016 corporate sponsor level
2016 annual meeting registration fees
_________________
Total enclosed
Please return with check payable to:
North American Burn Society (or NABS)
c/o Holly Schnetzler
1290 Hammond Road
Saint Paul, MN 55110-5959.
Secure payment available on line with your major credit card
Sponsorships include meeting registration for one attendee. Additional attendees are charged $250.00. Company
Sponsorships will also receive recognition in the program and acknowledged at the NABS Annual Meeting.
Lodging: Make lodging reservations directly with Alphenhof Lodge @ 307-733-3242 and request the “NABS Meeting” rate. A block
of Bavarian Rooms ($149.00 plus tax) have been reserved for the meeting. Reservations must be made before October 1, 2015. For
questions, contact us at www.nabsociety.org or email us at NABSociety@gmail.com.