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ACG 2014 Registration FormMail to: ACG, 6400 Goldsboro Road,Suite 200, Bethesda, MD 20817-5842Fax to: ACG at 301-263-9025.Fax with credit card number and signature.Web: Register online at www.acgmeetings.gi.org.Cancellation: Written notice of cancellationand requests for refunds must be received bythe College’s office by September 24, 2014.After this day, no refunds will be possible.Registration cancellations are not accepted bytelephone. An explanation must be provided inwriting. There will be a $50 administrative feeassessed for cancellation of any paid event.Refunds will be issued after the meeting. SeeCancellation Policy on page 121.ADA Compliance: Attendees of the ACGAnnual Meeting who need additionalreasonable accommodations or who havespecial needs should contact the ACG officeat 301-263-9000 no later than September 24.Please complete sections 1-5. Please print clearly.1. peRsonal InFoRmatIonFirst nameLast nameMUST circle all that apply: MD* DO* PhD Rn nP LPn PA PharmD Other *Please enter your 10-digit nPI number (required if U.S. physician)Look up your nPI number at npinumberlookup.org.Mailing Address Home address Work addressCity State/Province Zip / Postal Code CountryPhoneFaxEmail (required for meeting confirmation)I am bringing a mobile device or tablet: Yes no2. ReGIstRatIon FeesI am currently an ACG member.My application † for membership is attached.I have registered below at the member rates.(For membership information or to downloada membership application, visit www.gi.org.)†Registration will not be processed withoutmembership application.I am an ACG 2014 presenter: oral paper poster(includes FACG and MACG)Resident/Trainee/CandidateMember of ACGACG MemberASGE Practice Manager MemberPhysician / Exhibitor / Guest /Guest Physician / PharmDAllied Health Personnel(e.g. NP, RN, LPN, PA) orSpouse / Guest name, only if attending meetingResident/Trainee** (must attachletter from PD verifying status)Allied Health PersonnelCircle fee(s) based on attendee typePG Course and Annual Meeting, October 18–22PG Course Only, October 18–19Annual Meeting Only, October 20–223-day Clinical Review, October 17–19, includes PG Course,GI Pathology/Imaging, and GI Pharmacology3-day Clinical Review PLUS Annual Meeting, October 17–22aCG memBeRs$425 $0 $275$425 $0 $275$0 $0 $0$600 $200 $450$600 $200 $450(e.g. NP, RN, LPN, PA)Practice Managernon-memBeRs$750 $200 $575 $575$550 $200 $500 $500$300 $0 $150 $150$750 $425 $725 $725$850 $425 $800 $800Optional Friday Programs, October 17GI Pathology/Imaging; half-day/am (included in 3-Day Clinical)GI Pharmacology; half-day/pm (included in 3-Day Clinical)Practice Management; full dayGI Recertification; half-day/pmASGE Endoscopy Course; full day$200 $160 $175$200 $160 $175$275 $0 $200$150* $150* $150*$395 $200 $200$225 $225 $225 $225$225 $225 $225 $225$300 $300 $300 $200$175* $175* $175* $175*$495 $250 $250 $250*Recertification Course: Separate purchase of ACG’s module required.Boxed dinner provided. See page 14 for more details.**Your registration will not be processed without a letter from yourProgram Director verifying status.Postgraduate Course attendeesPlease indicate syllabus preference.Print version only ....... FREEUSB drive only ........... FREEPrint and USB ...............$302014PREAnnual Scientific Meeting attendeesPlease indicate syllabus preference.Print version only ....... FREEUSB drive only ........... FREEPrint and USB ...............$30125