2024 ACMG Corporate Educational Satellite Session Payment Form

SATELLITE SESSION SUPPORTER INFORMATION:*

ACCME PROVIDER INFORMATION, IF APPLICABLE:

MEDICAL EDUCATION COMMUNICATIONS COMPANY (or Third Party organizer) INFORMATION, IF APPLICABLE:

SESSION TITLE:*

PLEASE SELECT WHO IS PROVIDING PAYMENT:*

EMAIL ADDRESS TO SEND CONFIRMATION TO:*

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), 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
Wire Routing number: 026009593; ACH Routing number: 052001633
SWIFT/BIC: BOFAUS3N
Account number: 4460 4924 0744
Remittance Email: AccountsReceivable@acmg.net

Payment is by Credit Card or ACH. Select your method of payment and items below.

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

Application submitted on or before August 31, 2023$25,000.00

Payment for 2024 Satellite Symposium

Application submitted between September 1 and October 31, 2023$30,000.00

Payment for 2024 Satellite Symposium

Application submitted after October 31, 2023$40,000.00

Payment for 2024 Satellite Symposium

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

Eblast Banner Sponsorship related to Satellite Symposium

Banner ad on the ACMG Meeting website$3,500.00

Banner ad related to Satellite Symposium

Mobile App Alert$850.00

Mobile App ad purchase related to Satellite Symposium

Total $0.00

Payment Method
Credit	Express

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

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

SELECT THE APPROPRIATE FEE TO BE PAID BY ACH BASED ON SUBMISSION DATE

Application submitted on or before August 31, 2023: $25,000Application submitted between September 1 and October 31, 2023: $30,000Application submitted after October 31, 2023: $40,000ADDITIONAL PURCHASE: Eblast Banner ad sent to registered and prospective attendees: $2,500ADDITIONAL PURCHASE: Banner ad on the ACMG website: $3,500ADDITIONAL PURCHASE: Mobile app Alert: $850