63rd Annual Fall Assembly Registration September 17, 2021 HiddenAdministrationHiddenToday MM slash DD slash YYYY Registrant InformationName(Required) First Last Credentials (MD, DO, etc.) First Name for Badge (If Different Than Above) Group Name(Required) Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Email(Required)Email is required to receive confirmation and your e-syllabus Registration OptionsRegistration Type(Required) Member Physician - $200.00 Non-Member Physician - $250.00 Affiliate Member - $150.00 Life Member - $150.00 Resident/Student - $0.00 HiddenFall Assembly Cocktail Reception I will attend the Fall Assembly Cocktail Reception I will NOT attend the Fall Assembly Cocktail Reception HiddenGuest for Fall Assembly Cocktail Reception I will bring a guest. I will not bring a guest. HiddenGuest Name First Last ACOG Fellow I am an ACOG Fellow PaymentPayment Type(Required) Credit Card Check Check Number(Required) Total Coupon Credit Card(Required) American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Security Code Cardholder Name CAPTCHA Δ
