TELUSYS CUSTOMER SERVICE CENTER

STEP #1
MAKE YOUR SELECTIONS

STEP #2
CHECK YOUR INFORMATION

STEP #3
REVIEW / PRINT YOUR REGISTRATION

Register for the Philadelphia Academy of Surgery Events

Philadelphia Academy of Surgery
Scientific Program 2011/2012

* All items that are marked with an " * " MUST be provided. All other fields are optional.
*First Name:
*Last Name:
Title / Credentials:

Company/Organization Name:
*Address 1:
Address 2:
*City:
*State/Canadian Province:		(U.S./Canada)
International Province:
*Zip/Postal Code:		(Required for U.S.)
*Country:

*Phone:
Fax:

*E-mail Address:

Indicate your Registration Category:

DINNER FEE

Make your Registration Selections:

SELECT

EVENT / OPTION NAME

Selection
Not Available
During This Time Period

1. Scientific Program Registration - Practicing Physicians
Utilize the quantity box to indicate the number and name(s) of physicians that will attend. Select the date you wish to attend from the following selections:

Select one of the of the following:
October 3, 2011
November 7, 2011
December 12, 2011
January 9, 2012
February 6, 2012
March 5, 2012

DINNER FEE:

$75.00

Please indicate Total Number Attending of Practicing Physicians or Quantity:

Use the following input area to enter requested information, to list the names of extra attendees, practicing physician guests, or to submit your comments to the registration staff.

Selection
Not Available
During This Time Period

2. Scientific Program Registration - Trainee (Resident / Fellow)
Utilize the quantity box to indicate the number and name(s) of trainees that will attend. Select the date you wish to attend from the following selections:

Select one of the of the following:
October 3, 2011
November 7, 2011
December 12, 2011
January 9, 2012
February 6, 2012
March 5, 2012

DINNER FEE:

$60.00

Please indicate Number Attending of Trainees or Quantity:

Use the following input area to enter requested information, to list the names of extra attendees, trainee guests, or to submit your comments to the registration staff.

Payment Options:

Select your preferred method of payment and enter your billing contact information. If you are paying by credit card, the billing contact information should be the billing address of the card holder.

Payment information is not required for orders that total zero dollars.

Yes, my billing address is the same as the contact address above.

*First Name:

*Last Name:

Company:

*Billing Address1:

Address2:

*City:

*State *Zip Code (Required for U.S.)

*Country:

*I prefer to pay by check.

(This option is only available to PAS Fellows, on the Fellowship Roles, who are registering for themselves and their practicing-physician and trainee guests.)

Make check payable to:
Philadelphia Academy of Surgery

Mail your check to:
Philadelphia Academy of Surgery
P.O. Box 17314
Philadelphia, PA 19105

*I prefer to pay via Credit Card.

Please Note:

You are making this purchase directly from the Telusys Customer Service Center. TELUSYS will be the only name to appear on your credit card statement for these charges if you select "Pay via Credit Card" as your payment option.

Card Type:

Card Number:

Card Security Code (Security Code Help)
(3 or 4 Digit Number)

Exp. Date:

Month Year

I understand that these charges will appear as charges from "TELUSYS" on my CREDIT CARD STATEMENT. If I am making this purchase using someone else's credit card, I will notify the card holder that a purchase was made from "TELUSYS" and these charges will appear on their CREDIT CARD STATEMENT.