Registration Form Online Registration KRA 2017 Annual Meeting October 21, 2017 Hilton Garden Inn Louisville Airport Louisville, KY Online registration will be available until 10/11/2017. Afterwards, registration will be available onsite. Registration fees are subject to change. To lock in these rates, register now. Please select the category that best describes your status:* Select One Rheumatologist Non-Physician Provider Fellow Resident Student Other Medical Professional Administrator Industry Employee Fellowship/Residency Program:* Expected Graduation Year:* Select One 2017 2018 2019 2020 2021 2022 2023 2024 2025 Please Check ALL Areas of Practice Emphasis:* (Check all that apply) Ankylosing SpondylitisLupusRheumatoid ArthritisSjogren’s SyndromeFibromyalgiaOsteoarthritisSclerodermaDoes Not ApplyGoutPsoriatic Arthritis How did you learn about this conference? (Check all that apply) Advertisement in Professional JournalMember NewsletterWebsiteCalendar/Monthly ListingRegistration Brochure MailerWord of Mouth/ColleagueEmail Membership Application KRA Membership Dues (Join or Renew Today) and attend the KRA Annual 2017 Meeting complimentary! I am Applying for Active Membership $50 *If you pay the membership fee, you may register for the meeting complimentary. Registrant Information First Name:* Last Name:* Degree(s): Badge First Name:* Address 1:* Address 2: City:* State:* Zip Code:* Country:* Phone:* Fax: Email:* Address Type:* HomeOffice Meeting Registration* Physician – Member Complimentary Physician – Non Member $50 Non Physician Provider $25 Student Complimentary Fellow Complimentary Resident Complimentary Industry Employee - Supporting Industry Employee whose company is already supporting KRA OR Industry Medical Science Liaison (Proof of MSL Title may be required before confirmation of registration) $175 Industry Employee - Non-Supporting Industry Employee whose company is NOT already supporting KRA $1,250 Your submission will need to be approved prior to confirmation of your registration. Approval may be based on current Industry support. To find out if your company is currently supporting KRA, please contact Brittany Kallman in the Registration Department at (847) 264-5963 or by email at firstname.lastname@example.org. TOTAL REGISTRATION FEE: The KRA requires full payment for registration fees by check or credit card. Payment Information (must be made in U.S. dollars) Please note: If paying by credit card, the name WJ Weiser & Associates (the management company of Kentuckiana Rheumatology Alliance) will appear on your statement. CheckCredit Card Billing Address:* ZIP:* Card Type:* Visa MasterCard American Express Name on Card:* Card Number:* Expiration Date: (mmyy)* Card Verification #:* If paying by check, make check payable to: WJ Weiser & Associates. Mail payment to: Kentuckiana Rheumatology Alliance Two Woodfield Lake 1100 E. Woodfield Road, Suite 350 Schaumburg, IL 60173 I have read, understood and agree to the electronic delivery of the data collected and payment amount.I Disagree SIGNATURE: E-mail address Telephone Number By selecting "I Agree" I represent and acknowledge that: I have read, understood, and consented to electronic delivery of the data collected and payment entered above. I have granted authorization to KRA in association with WJ Weiser & Associates, Inc. to charge the amount indicated on the credit card provided. I am the authorized user of the credit card listed above and that the associated information entered (account holder name, account number, billing address, etc.) is accurate. I intend the act of selecting "I Agree" to be my legal signature to this agreement. Enter Security Code: 8071 Registration Cancellation and Refund Policy Registration refund requests must be submitted in writing to the KRA Executive Office no later than 9/18/2017. All refund requests will be subject to a $10.00 processing fee. No refunds will be made after 9/18/2017.