ADMSEP 2013 Meeting eRegistration and ePayment

Directions:   Meeting eRegistration is a 3 step process. 

Step 1:  Please provide the information below, review, then click "submit" at bottom.  Questions?  

Is this for 2013/2014? (y or n)         
Is this for a different year? If so enter the year         
Membership Status (if you are unsure, please view membership policy and/or comment in note at bottom)   
From the choices at right, please enter the item number you desire (#1-4)
  		-Active (Voting) Member (benefits include a subscription to Academic Psychiatry, listserv access, ADMSEP Newsletter, & members-only ADMSEP web access)
1.  US Dues $295
2.  International Dues $350
 
Associate (Non-voting) Member (benefits include access to listserv, ADMSEP Newsletter, members-only ADMSEP web access)
3.  House Officer Dues $20
4. Associate (Non-voting): Coordinator/Administrator Dues $20
       
Last Name      
First Name      
Title (MD, PhD, Ed.D. etc)
Institution Name:      
Street Address      
Address (cont)
Phone  (e.g.. 223-446-5000)      
Fax (e.g.. 223-446-5000)      
Email      
City/Province      
State      
Zip      
         
Medical School Affiliation (if different than institution):     
       
Current position (please 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, Dept of Psychiatry        
  Other (fill in the blank)      
       
Please check the groups to which you belong currently as a member of:    
AADPRT        
AAP
AACDP        
AACAP        
       
The next 3 questions concern meeting registration:
 
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 guests) wanting vegetarian lunch/dinners 
Please specify the # of persons (you and/or guests) wanting gluten-free meal                  
       
Note (optional):   
       
**Before you click submit, could you please email us a photo of yourself so we may include it with your entry in the admsep online directory?  (in the "members only" area)

Prove you are not a robot spammer

Now click submit below
       

Please note:
-After clicking submit, you should see a web page which echos your responses.  The payment page link will be revealed at that time at the page's bottom.
-However, if you see that you made a mistake at the confirmation page, simply click the "back" button on your browser, make the correction(s), and click submit again (it will be clear from the timestamp which submission is your final version).  You do not have to reenter all the info just to correct a mistake as the form "remembers" what you put in previously.
-You should recieve a confirmation email which includes your submission content above

Questions/Help? 
-About the application process:   Dr. Gary Beck.
-If you have a question about the form itself, please contact webmaster.

r11/30/12