SGSU 2018 Reg Form

     65th SGSU
     James C. Kimbrough
     Urological Seminar

The Scottsdale Resort at McCormick Ranch
Scottsdale Arizona, January 10-14, 2018

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We are delighted you will be joining us!

Note: you may pay your activity/registration fees by credit card or check on the next page. If you require an invoice to be submitted for payment, please choose "pay by check" option and an invoice/confirmation will be emailed to you.

Kimbrough Registration - Scottsdale 2018

Categories and Rates *

Active Duty Military/Reservist - $275	SGSU Member (non-active duty) - $375
Current VA Urologist - $375	SGSU Senior Member - $275
Allied Health Pro, APP, PA, NP - $245	Non-Member Physician - $575
Resident-Fellow-MedStudent-GMO - $345

Select sub-category *

*Activity fees include badge, materials and admittance to all educational programs/sessions, breakfast and related meals. Activity/Registration fees do not include annual membership dues.

Please provide the information below: (Please type as you wish your name to appear in print)

First Name *

Middle

Last Name *

First Name for Badge *

Organization / Facility

Address 1 *

Address 2

City *

State/Province/Region *

Zip/Postal Code *

Degrees (i.e., MD, FACS)

Service/Agency

Military Rank

Other Military Rank

Country *

Email Address: (for confirmation) *

Phone (in case of emergency) * 🛈

Staying at Group Hotel? *

Yes

No

Add Spouse and/or Guest Registration:
Fee includes badge, daily breakfast (Thurs-Sun), access to meeting sessions, breaks, exhibits, and evening social events including the President's Welcoming Reception and Littrell Awards Evening. This package does not include the Business Lunch or CME.

Add Spouse / Guest - $125

Add 1 Additional Guest - $125

Add 2 Additional Guests - $250

Spouse / Guest Name(s) for Badge:

Spouse/guest email address for info and confirmation:

Optional Activities - please check events you will be attending

Optional: President's Welcoming Reception, Weds - $45

Optional: Kathy and Preston Littrell Awards Evening, Sat - $45

Optional: GU Bowl Party/Networking Event - no cost

Optional: Business Lunch Mtg - no cost, members only

Optional: Make a Supporting Contribution (All Benefactors shall be acknowledged in the meeting program. Thank you for helping SGSU!)

Benefactor Contribution Level 1 - $200

Benefactor Contribution Level 2 - $100

General Comments:

AGcode

Click "Continue" button below to review your order and payment options.

Cancellation Policy: You may cancel or change your registration up to 30 days prior to the meeting (on or before December 10, 2017) without penalty. You will receive a full refund promptly. Cancellations for any reason received after December 10 cannot be refunded. However, your registration is transferable to an associate or if you decide not to use it we will credit it to a future meeting less a $100 processing fee. No shows are not refundable.

ADA: Please let us know if you are disabled and require special assistance. Contact us with a description of your needs at 714-550-9155.

NEED HELP: Please call or email us at 714-550-9155 (info@sgsu.org) for assistance. Thank you.