Registration Kentuckiana Rheumatology Alliance 2020 Annual Meeting September 26, 2020 Virtual Meeting Thank you for your interest in attending this meeting. Online registration is now closed. Online registration will be available through Saturday, September 26, 2020 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 Industry Employee Fellow Full Time Administrator Nonphysician Provider Other Other Medical Professional Physician Researcher Resident Student/Trainee Fellowship/Residency Program: Expected Graduation Year: Select One 2020 2021 2022 2023 2024 2025 How did you learn about this conference? Select One Advertisement in Professional Journal Calendar/Monthly Listing Email Member Newsletter Registration Brochure Mailer Website Word of Mouth/Colleague Please Check ALL Areas of Practice Emphasis: (Check all that apply) Ankylosing SpondylitisPsoriatic ArthritisFibromyalgiaRheumatoid ArthritisGoutSclerodermaLupusSjogren’s SyndromeOsteoarthritisDoes Not Apply INDUSTRY EMPLOYEES ONLY Industry Employees who are interested in supporting KRA or attending this meeting should contact JP Baunach (firstname.lastname@example.org) for more information. Registrant Information Address Type: HomeOffice Membership Application If you pay the membership fee, you may register for the meeting complimentary. I am applying for membership as an: Active Member (Physician) $50 Affiliate Member (Nonphysician Provider) $25 Meeting Registration Registration Categories Fees Physician – Member Complimentary Nonphysician Provider - Member Complimentary Physician – Nonmember $75 Nonphysician Provider – Nonmember $50 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 Gyuricza in the Registration Department at (847) 264-5963 or by email at email@example.com. TOTAL REGISTRATION FEE: The KRA requires payment for registration fees by check or credit card. Payment Information (must be made in U.S. dollars) CheckCredit Card --Select Card-- Visa MasterCard American Express If paying by check, make check payable to: Kentuckiana Rheumatology Alliance 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. SIGNATURE: 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: 859146 This is to test whether you are a human visitor and to prevent automated spam submissions. Registration Cancellation and Refund Policy Registration refund requests must be submitted in writing to the KRA Executive Office no later than Friday, September 4, 2020. All refund requests will be subject to a $10.00 processing fee. No refunds will be made after 9/4/2020.