Annual Meeting & Subspecialty Day Preregistration Form

REGISTER ONLINEwww.aao.org/2013

PREREGISTRATION DEADLINEEarly Fee Deadline Aug. 7Register Via Mail, Fax or Web — to receive badge/materials in the mail Oct. 2Register Via Web only — www.aao.org to pick up badge/materials onsite Oct. 23

MAILING ADDRESSDept. #34045

PO Box 39000San Francisco, CA 94139

USAFax: 415.561.8575

1 AAO/AAOE Member/Customer Number 2 □

□ CHECK IF PERMANENT ADDRESS CHANGE (This address will be used on all AAO correspondence and subscriptions.)

3 Family Name Given Name Middle Initial Degree

Employer/Practice Position

Address

City State/Province Postal/ZIP Code Country

Email (required) Telephone Fax

4 □ ANNUAL MEETING REGISTRATION Category 4 $ (ex: Academy Member; AAOE Member; Health Professional) ANNUAL MEETING FEE

□ ACADEMY PLUS COURSE PASS □ $175 Early; Academy and AAOE Members; Nonmembers (by Aug. 7) (Check One) □ $225 Prereg; Academy and AAOE Members; Nonmembers (Aug. 8 – Oct. 23) □ $100 Academy Member in Training $ Academy Plus is a Course Pass that gives you access to all 350 Instruction Courses. COURSE PASS FEE Individual tickets to Academy and AAOE instruction courses will not be sold. Skills Transfer Labs, Breakfast with the

Experts, AAOE Roundtables, Ticketed Special Events, and AAOE Coding Courses are not included in the pass.

6 □ SUBSPECIALTY DAY REGISTRATION Category 6 $ (Check One) (ex: Academy Member; Nonmember Physician; Commercial Rep.) SUBSPECIALTY DAY FEE

□ Cornea □ Glaucoma □ Neuro-Ophthalmology □ Oculofacial Plastic Surgery □ Pediatric Ophthalmology □ Refractive Surgery □ Retina

7 □ AAOE CODING REGISTRATION (check one or both) □ Conquering ICD-10-CM □ Coding Camp 7 $ CODING FEE(S)8 NONMEMBER PHYSICIAN IN TRAINING CERTIFICATION (Must be completed by your program director to verify enrollment status in a residency program. Otherwise, you will be charged the full amount.)

I certify that during the 2013 Annual Meeting and Subspecialty Day the above individual will have full–time student status:

Supervisor’s Name Supervisor’s Signature Institution/Department

□ SPOUSE/GUESTS AND YOUTH (Complete this section only if you wish to register your spouse/family member for the Annual Meeting and pay appropriate fees. Attach additional sheets if necessary.)

$ Family Name Given Name Category (SPS or YTH) Fee

$ $ Family Name Given Name Category (SPS or YTH) Fee SPOUSE/GUEST FEE

□ TICKETED EVENTS AND TOURS (List in order of preference; attach additional sheets if necessary.) $ TICKET AMOUNT Total

$ 2013 AAO or AAOE DUES (if due)

$ _________________________________

TOTAL ENCLOSED

(Add lines 4, 5, 6, 7, 9, 10 & 11) PAYMENT METHOD □ CHECK ENCLOSED (Payable to AAO in US Dollars, drawn on a US bank.) □ VISA □ MASTERCARD □ DISCOVER □ AMERICAN EXPRESS □ JCB

Name of Cardholder Exp. Date

Credit Card Billing Address (if different than Shipping) City, State/Province, Postal/ZIP Code, Country

Signature of Cardholder E-mail Address of Cardholder

Event # Day/Time Course /Tour Name Fee Individual tickets to Instruction Courses will not be sold. See Academy Plus Course Pass.

2013 Annual Meeting & Subspecialty DayPreregistration and Ticket Sales OpenFor Academy and AAOE June 26For nonmembers July 10

CancellationsTo cancel your registration and receive a refund, a written request must be received by October 2. There will be a per-person, per-meeting cancellation processing fee of $75 or your total registration and course pass fee, which-ever is less. No refunds will be processed after October 2.

Preregistration Form Instructions1 2 3 Name/ADA/Address• Yourname,degree,cityandstateorcountrywillbeprintedonyourbadge.• Onlyonedegreecanbelistedonbadges.• Includeyourcurrenttelephonenumber,faxnumberandemailaddress.• IfyouneedanyoftheauxiliaryservicesidentifiedintheAmericansWith

Disabilities Act, please check the box on this form and indicate your needs on line 2.

4 Annual Meeting RegistrationComplete this section only if you are attending the Annual Meeting.

Academy Plus Course PassAcademy Plus is a course pass that gives you access to all 350 instruc-tion courses. Individual tickets for Academy and AAOE instruction courses will no longer be sold. Due to their unique nature, Skills Transfer labs, Break-fast With the Experts, AAOE roundtables, ticketed special events and AAO Coding courses are not included in the pass. For more information, visit www.aao.org/pass.

Early Reg. Prereg. FeeCategory Fee Deadline Deadline Aug. 7 Oct. 23

Active Academy Member $0 $0Including Fellow, Member, Member in Training, Confirmed Candidate, Life Member, Associate Member, Industry Member and International Member. 2013 dues must be paid.

Retired Member $200 $200Including Fellow and Member.

Affiliate Member $400 $450Available to affiliate members from Philippines and India.

Nonmember Physician $875 $925

Nonmember Physician in Training $250 $275Including Residency Program and Fellowship participants.

AAOE Member $0 $0Must be a member by October 23 to qualify.

Health Professional $150 $200 Including PhD, DVM, COE, MBA, Healthcare Administrator, Technician, Assistant, Nurse, Office Support Staff, Medical Student, Intern, Orthoptist, Ophthalmic Photographer, AAOE Billing Member or other health professionals. Does not include Optometrists or Industry Representatives.

Commercial Representative $1,500 $1,500For those with legitimate business reasons for attending but who do not have a product or service to exhibit. To register contact exhibitions@aao.org.

Do not use this form to register.

Subspecialty Day RegistrationComplete this section only if you are attending Subspecialty Day. Be sure to indicate your primary meeting.

Cornea, Glaucoma, Neuro-Ophthalmology, Oculofacial Early Reg Prereg. FeePlastic Surgery, or Pediatric Ophthalmology Deadline DeadlineOne-Day Meetings: Saturday Aug. 7 Oct. 23

Academy Member $400 $450

Academy Member in Training $200 $250

Academy US Member, 1st & 2nd Year in Practice $300 $350

Academy Retired Member $300 $350

Nonmember Physician $500 $550

Nonmember Physician in Training $250 $300

AAOE/Health Professional $400 $450

Commercial Representative $600 $650

Early Reg Prereg. FeeCategory Fee Deadline Deadline Aug. 7 Oct. 23

Academy and AAOE Member $175 $225

Academy Member in Training $100 $100

Nonmember $175 $225

Early Reg. Prereg. FeeHalf-Day Meetings: Saturday Fee Deadline Deadline Aug. 7 Oct. 23

Conquering ICD-10-CM for Ophthalmology $290 $310

Coding Camp $230 $250

Early Reg. Prereg. FeeCategory Fee Deadline Deadline Aug. 7 Oct. 23

Spouse/Guest (age 18 and above) $60 $70

Youth (age 17 and under) $0 $0

Refractive Surgery or Retina Early Reg Prereg. Fee

Two-Day Meetings: Friday & Saturday Fee Deadline Deadline Aug. 7 Oct. 23

Academy Member $700 $750

Academy Member in Training $300 $350

Academy US Member 1st & 2nd Year in Practice $500 $550

Academy Retired Member $500 $550

ISRS Member* $600 $650

ISRS Member in Training* $300 $350

Nonmember Physician $875 $925

Nonmember Physician in Training $400 $450

AAOE/Health Professional $700 $750

Commercial Representative $975 $1,025

*For Primary Refractive Surgery Only — must be an active ISRS member with 2013 dues paid.

AAOE Coding RegistrationComplete this section only if you are attending Conquering ICD-10-CM for Ophthalmology or Coding Camp. If you wish, you may register without registering for the Annual Meeting.

You may register for one or both courses.

Nonmember Physician in Training CertificationThissectionmustbefilledoutbyyourprogramdirectortoverifyenrollmentstatusinaresidencyprogram.Withoutthisverification,youwillbecharged the full nonmember physician fee.

Spouse/Guests and YouthEnter the names of your spouse and family members. Registration fees are indicated below. For more detailed information, see the Spouse & Guest Program.

ChildrencannotbeadmitttedtoanyaspectofthescientificprogramduetothescientificnatureoftheeducationalprogramsandtheAcademy’sdesireto maintain an environment conducive to learning.

Ticketed Events and ToursIf you selected Ticketed Events or Tours, complete this section. The only ticketed events are Skills Transfer labs, Breakfast With the Experts, AAOE roundtables, special events, and tours.

Note: Individual tickets will not be sold for the instruction courses. See Academy Plus Course Pass.

Academy and AAOE DuesIf your 2013 membership dues have not been paid, include your dues payment on line 12. Registration materials will be held until any owed 2013 dues are paid.

Payment MethodAdd lines 4, 5, 6, 7, 9, 10 and 11 and enter the total on line 12. Your registration will not be processed without full payment.

The American Academy of Ophthalmology does not permit attendance or participation by optometrists at any educational activity at its Annual Meeting.

Refer to www.aao.org/2013 for onsite pricing. Most categories increase onsite.