VEITHsymposium, including the Advances in Vascular Imaging and Diagnosis Sessions Individual Registration

* First Name:
* Last Name (Surname, Family Name):
Degree: If you are a physician/surgeon/professor, please select either MD or DO as your degree	If Other:
National Provider Number (NPI):
* Physician or Non-Physician:	Physician Non-Physician
Specialty:	If Other:
Affiliation:
* Cleveland Clinic Employee?	Yes No
* Address Type:	Home Other
* Address:
* City:
* State/Province:
* Zip/Postal Code:
* Country:
* E-Mail: A valid registrant's email address is required for confirmation and CME Certification This e-mail address can be used only once
Alternate E-Mail (Secretary/Assistant):
* Phone:	U.S. Telephone: - - or International Telephone:
Cell Phone:	U.S. Cell Phone: - - or International Cell Phone:
Fax:	U.S. Fax: - - or International Fax:

Vascular Technicians, Sonographers, Residents and Nurses
Friday and Saturday	$450
Friday only	$250
Saturday only	$250
Physicians, Nurse Practitioners, and Physician Assistants
Friday and Saturday	$650
Friday only	$349
Saturday only	$349

Discount Code (If applicable)
Credit Card Payment (Pay now)	Select this option to pay securely online now
Check	Please note that checks must be received by 10/31/2024 and a copy of the registration form should accompany the check. Please make checks payable to the Cleveland Clinic Educational Foundation and mail to: The Cleveland Clinic Educational Foundation Attn: EHCC081 P.O. Box 931653 Cleveland, OH 44193-1082 If sending by courier such as Federal Express, UPS or DHL, please send to: The Cleveland Clinic Educational Foundation Attn: Lockbox 931653 4100 West 150th Street Cleveland, OH 44135
Wire/Bank Transfer	Wire transfers will incur an additional $30 to the registration fee. Please note that wires must be received by 10/31/2024 and that the name of the registrant/registrants MUST appear on the wire transfer. Please send e-mail to registrar@AVIDsymposium.org for bank instructions
Complimentary	Select this option if your registration is complimentary.
Offline Credit Card	Credit Card will be processed manually at a later time.

I have read and accept that there is a $95 cancellation fee if canceled in writing by October 19, 2024. No refunds will be made thereafter.