Corporate Educational Satellite Session 2023 Payment Form

SATELLITE SESSION SUPPORTER INFORMATION: *

ACCME PROVIDER INFORMATION, IF APPLICABLE:

MEDICAL EDUCATION COMMUNICATIONS COMPANY INFORMATION, IF APPLICABLE:

SESSION TITLE: *

PLEASE SELECT WHO IS PROVIDING PAYMENT: *

Payment Terms:

Full Application Processing payment is due at the time of application submission, or within 10 business days.
Payments can be made via credit card (Visa, MasterCard, Discover or American Express), check, wire transfer or ACH remittance.
Applications will be rejected if payment is not received within 10 business days.

Wire Transfer/ACH Remittance Information:
Beneficiary Name: ACMG
Bank Name: Bank of America
Bank Address: 6822 Wisconsin Ave Bethesda, MD 20815
Routing number: 026009593
SWIFT/BIC: BOFAUS3N
Account number: 4460 4924 0744
Remittance Email: AccountsReceivable@acmg.net

Checks:
Checks should be made payable to the American College of Medical Genetics and Genomics (ACMG) and mailed to:

ACMG
7101 Wisconsin Ave., Suite 1101
Bethesda, MD 20814

PAYMENT BY WIRE TRANSFER or ACH:

Please check this box if paying by wire transfer or ACH and send an email to acmgmeeting@acmg.net

CREDIT CARD PAYMENT – SELECT APPROPRIATE FEE BASED ON SUBMISSION DATE (if not paying by credit card, do not check these boxes):

Application submitted on or before September 5, 2022 $ 25,000.00

Application submitted between September 6 and October 31, 2022 $ 30,000.00

Application submitted after October 31, 2022 $ 40,000.00

Eblast Banner ad sent to registered and prospective attendees $ 2,500.00

Banner ad on the ACMG Meeting website $ 3,500.00

Total $ 0.00

Payment Method

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country