STA Annual Meeting Registration Form

Registration Fees

Registration fees include: continental breakfast each day, two refreshment breaks, one physicians reception, one dinner, two lunches, field trips, and course materials.

BEFORE DECEMBER 22, 1996

STA Members$ 300.00
Non-Members$ 350.00
AFTER DECEMBER 22, 1996
STA Members$ 350.00
Non-Members$ 400.00
Non-Physicians/Residents/Students BEFORE DECEMBER 22, 1996
STA Members$ 200.00
Non-Members$ 300.00
AFTER DECEMBER 22, 1996
STA Members$250.00
Non-Members$350.00

Registration

(Please type or print as you want your name to appear on your name badge.)

Your name (First Last):

Your email address:

Your Daytime Telephone Number (With Area Code):

Your Evening Telephone Number (With Area Code):

Your Fax Number (With Area Code):

Institution or Organization:

Please type your mailing address below:
Include institution, street address, city, state, country, and postal code.

STA Membership Number (leave blank if none):

Payment

Total Payment:

MasterCard
Visa

Card Number: Expiration Date:

Submit the Registration Information

Refund Policy

Full refund less $50 application fee may be obtained if cancellation is postmarked on or before December 22, 1996.

Fifty percent refund if cancellation is postmarked December 23- January 10, 1996.

No refund after January 10.

All cancellations must be in writing.