BCPMA Registration Form

Please complete the form below to register for the British Columbia Podiatric Medical Association (BCPMA) Annual Scientific Conference 2013: April 26-28, at the Delta Victoria Ocean Pointe Resort & Spa in Victoria, BC. Please ensure to complete all fields that are required. Any questions, please contact the BCPMA office at 604.985.3338 or email info@bcpodiatrists.ca.

Step 1 - Contact Information

Please type your name how it should appear on your name-badge.

Prefix

Dr. Prof. Mr. Mrs. Ms.

Name

Surname

Credentials (optional)

Practice/Clinic Name (optional)

Address

City

Country

Canada United States

Prov / State / Region

AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon

AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming

Postal / ZIP Code

Telephone

Fax (optional)

Email

Website (optional)

YES, please list my contact information on the conference participant list.
NO, please DO NOT list my contact information on the conference participant list.

Select Registration Category

BCPMA Member: CAD $392.00 CPMA / Region VII / APMA Member: CAD $392.00 Non-Member: CAD $795.00 Student: CAD $75.00

Please select the day(s) you wish to attend:

Friday

Saturday

Please specify who is a member:

I will attend the CPR Course: Friday, April 26, 2013 at 13:00-16:00: CAD $150.00

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If registering additional delegates on the same form, all delegates must be from the same address/location.

Delete Delegate

Prefix

Dr. Prof. Mr. Mrs. Ms.

Name

Surname

Credentials (optional)

Email

YES, please list my contact information on the conference participant list.
NO, please DO NOT list my contact information on the conference participant list.

Select Registration Category

BCPMA Member: CAD $392.00 CPMA / Region VII / APMA Member: CAD $392.00 Non-Member: CAD $795.00 Student: CAD $75.00

Please select the day(s) you wish to attend:

Friday

Saturday

Please specify who is a member:

I will attend the CPR Course: Friday, April 26, 2013 at 13:00-16:00: CAD $150.00

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+ ADD ANOTHER DELEGATE

Step 2 - Billing Information

Please select this box if your billing information is the same as your above contact information

Practice/Clinic Name (optional)

Address

City

Country

Canada United States

Prov / State / Region

AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon

AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming

Postal / ZIP Code

Telephone

Fax (optional)

Email

Step 3 - Payment

Method of Payment

Credit Card

Credit Card charges will appear as "CongressWorld" on your statement and converted to your currency.

Credit Card Number

Name on Card

Expiry Date

01 02 03 04 05 06 07 08 09 10 11 12

2024 2025 2026 2027 2028 2029 2030 2031 2032 2033

Security Code

3 or 4 digit code on the back

Cheque

Send a Cheque

Send a cheque made payable to "BCPMA" to the mailing address listed below. Please ensure to include a copy of your registration with payment.

Mailing Address:
BCPMA
c/o CongressWorld Conferences Inc.
#220 - 445 Mountain Highway
North Vancouver, BC V7J 2L1
Canada

Step 4 - Send Registration Form

I accept the Term of Service for the BCPMA Annual Scientific Conference 2013. If you request a cancellation up to 30 days before the conference, a refund will be issued, less a processing fee of CDN $100.00 per person. Cancellation must be received in writing at the BCPMA office. Please note all refunds will be processed after the conference has been completed. No refunds will be granted if post-marked after March 26, 2013 or for non-attendance at the conference.