Attendee Registration Form
NCS-ACOFP 2025 Annual Conference
Name and Suffix (e.g., DO, MD, PA, FNP, OMS)
*
First Name
Last Name
Suffix
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.
Please indicate which meals you plan to attend:
*
Friday breakfast - check this only if you are not staying at the hotel and you wish to eat the breakfast buffet offered to hotel guests. If you check this, a breakfast voucher can be provided.
Friday lunch
Friday reception
Saturday breakfast
Saturday lunch
Sunday breakfast -check this only if you are not staying at the hotel and you wish to eat the breakfast buffet offered to hotel guests. If you check this, a breakfast voucher can be provided.
Registration Fees
*
prev
next
( X )
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
Quantity
1
2
3
4
5
6
7
8
9
10
Donation to Sponsor Student Attendance
Your donation will be used to assist with paying hotel costs for students to attend the conference.
$
100.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit
Should be Empty: