ADMSEP 2010 Meeting eRegistration and ePayment
Directions
: This is a 3 step process. Please follow each step as directed to completion.
Step 1
: Please provide the information below, review, then click "submit" at bottom. You will then be taken to step 2, the meeting fee details.
Questions?
Please check the meeting you are paying for:
2010 Other:
Membership Status (if you are unsure, please view
membership policy
and/or comment in note at bottom)
Please choose one from below
Active
Non-Member
House Officer
Student
Last Name
Institution Name:
First Name
Title (MD, PhD, Ed.D. etc)
Street Address
Phone (e.g.. 223-446-5000)
Address (cont.)
Fax (e.g.. 223-446-5000)
City
E-mail
State/Province
Zip Code
Medical School Affiliation (if different than institution):
Current position (check as many as apply)
Lecturer in Human Behavior, Psychopathology, or Clerkship
Clinical Attending for Psychiatry Clerkship
Director or Site Coordinator, Clerkship in Psychiatry
Director, Psychopathology or equivalent course
Director, Human Behavior, Interviewing or equivalent course
Asst or Assoc Director, Medical Student Education
Director, Medical Student Education
Director or Vice-Chair, Psychiatry Education
Chair, Department of Psychiatry
Other:
Please check if you are also currently a member of:
AADPRT
AAP
AACDP
Please let us know the names of the guest(s) you will be bringing to the meeting (separate by comma; meal charges apply, as per next screen):
Please specify the # of persons (you and/or guest(s)) wanting vegetarian lunch/dinners
Pick one from the dropdown list
1
2
3
4
Note (Optional):
Important: Please do not click "submit" until you have completed the form in full and reviewed. After clicking submit, you will then be taken to the next step, meeting fee details.
Questions?
12/10/09