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DELEGATE REGISTRATION FORM
(Please print)
Family Name _________________________________ First Name (as it will appear on badge) ________________________________
Specialty Classification (i.e. Infectious Disease, Medical Microbiology, Clinical Microbiology, lab technologist, etc.)
___________________________________________________________________________________________________________
Position/Title _________________________________________________________________________________________________
Institution/Organization _________________________________________________________________________________________
Department __________________________________________________________________________________________________
Mailing Address _______________________________________________________________________________________________
City _______________________________________________
Province ________________________________________________
Country ____________________________________________ Postal Code ______________________________________________
Telephone (office) ___________________________________
Fax _____________________________________________________
E-mail _______________________________________________________________________________________________________
Please specify any food allergies or other dietary requirements __________________________________________________________
Yes No Do you give permission to have your name, organization, city and email address included on the list of participants that
AMMI Canada – CACMID shares with delegates and sponsors?
Yes No Is this your first time attending an AMMI Canada - CACMID conference?
Royal College Membership ID # _____________________________
AMA Membership ID # ____________________________________
MEMBER
AMMI Canada Membership ID # ____________________________
CACMID Membership ID # _________________________________
NON-MEMBER
Collaborating Society ___________________________________________________________________________
Other ________________________________________________________________________________________
Registration for Pre-Conference Activities (Wednesday, April 15)
CCM Workshop
Trainees’ Day
$80
No Charge
$ ____________
Full Conference Registration (Thursday, April 16 - Saturday, April 18)
Fee includes: welcome reception, refreshment breaks and lunch Thursday, Friday and Saturday.
Registration
Early Bird Rate
On or Before March 2
$400
Regular Rate
After March 2
$500
Amount
$ ____________
Member – Full Conference
Non-Member – Full Conference
$500
$600
$ ____________
Student * – Full Conference
$175
$225
$ ____________
*A letter of attestation from the teaching institution indicating the registrant is enrolled in a full-time program must accompany
the registration.
Please complete both pages of the registration form
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Daily Conference Registration
Daily registration is available for single days only. Multiple day attendees should register for the full conference.
Please specify day of attendance:
Thursday
Friday
Saturday
Early Bird Rate
On or Before March 2
$250
$300
$75
Member – Single Day
Non-Member – Single Day
Student * – Single Day
Regular Rate
After March 2
$300
$350
$75
Amount
$ ____________
$ ____________
$ ____________
*A letter of attestation from the teaching institution indicating the registrant is enrolled in a full-time program must accompany
the registration.
Optional Events – No Charge
Welcome Reception (Thursday, April 16)
AMMI Canada Sections & AGM (Thursday, April 16)
CACMID AGM (Friday, April 17)
CCM AGM (Saturday, April 18)
Optional Events – Ticketed
Cost/person
Closing Dinner - Adult
Closing Dinner - Child
# of persons
$65
$35
_____
_____
Subtotal A (Total of all items from both pages)
$ _________________
Less $100 hotel reservation discount
$ _________________
$ ____________
$ ____________
(Reservation # _______________________)
Less $35 Collaborating Society Discount
$ _________________
Subtotal B (Subtotal A minus discounts)
$ _________________
HST (15%) 123956120RT0001
$ _________________
Total Payable
$ _________________
Payment by Credit Card: Visa
MasterCard
Card No.: __________________________________________________________
Expiry Date: ____________________
Cardholder Name: ______________________________________________ Signature:______________________________________
Payment by Cheque or Money Order: Please make your cheque or money order, payable to “AMMI Canada – CACMID Conference”.
Payment Policy: Conference registrations are not considered confirmed until full payment is received. All conference registration fees
must be paid prior to the commencement of AMMI Canada - CACMID Annual Conference 2015 (April 16, 2015). This includes payment for
all optional events.
Cancellation Policy: Cancellation requests must be made in writing. Those received on or before March 2 will receive a full refund less a
$50 administration fee. Those received after March 2 will receive a 50% refund, less a $50 administration fee. Refunds will be processed
after the conference. Registrations may be transferred at any time without penalty.
Inquiries: For registration inquiries, please contact Unconventional Planning at Tel: (613) 721-7061 or (888) 625-8455 (North America
only), Fax: (613) 721-3581 or e-mail: [email protected]. Please visit www.ammi.ca or www.cacmid.ca for
conference information.
PLEASE SUBMIT YOUR REGISTRATION FORM USING ONE OF THE OPTIONS BELOW:
Mail
Fax
AMMI Canada – CACMID 2015
100 – 32 Colonnade Road
Ottawa, ON K2E 7J6
Canada
613-721-3581
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