Attendee Registration Form
NCS-ACOFP 2024 Annual Conference
Name
*
First Name
Last Name
Email
*
example@example.com
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
If you are a practicing physician, please enter the physical address of your practice.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
The registration fee includes breakfast, lunch and snacks. If you have any dietary allergies, please describe below.
The registration fee includes the Friday evening reception. Do you plan to attend?
*
Yes
No
Registration Fees effective July 3, 2024.
*
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NCOMA or NCS-ACOFP Member
(You must be a member of one of the NC chapters for this rate to apply.)
$
525.00
Non-member Physician
(Rate applies to individuals who are not a member of NCS-ACOFP or NCOMA. Membership will be verified.)
$
575.00
Active Duty Military Physician (not a member)
$
325.00
Retired Physician
$
375.00
Student
$
45.00
Resident
$
100.00
Other Health Care Professional (PA, RN, FNP, etc. )
$
350.00
Guest (For Friday evening reception only)
$
40.00
Donation to Sponsor Student Attendance
Your donation will be used to assist with paying hotel costs for students to attend the conference.
$
100.00
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Item subtotal:
$
0.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit
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