31th PAN-AMERICAN CONGRESS
OF OPHTHALMOLOGY

August 4 – 8, 2015 … Bogotá, Colombia

REGISTRATION FORM
PLEASE FILL IN THIS FORM WITH BLOCK LETTERS
ID PAAO (optional): / Degree: MD q PhD q Technician q Nurse q
Name:
Last name(s) / First Name / Middle Initial
Address:
Street address / Apt/Ste. #
City / State / Zip Code / Country
Telephone: q office; q home; q cellular / Fax / E-mail (BLOCK LETTERS)
Name of Companion(s):
CONGRESS REGISTRATION ALL PRICES IN US DOLLARS
Category / Early Bird February 28, 2014 / Until
December 31, 2014 / Until July 1, 2015 / On SITE
August 4-8, 2015 / REGISTRATION FEE
INCLUDES:
PAAO Active Member* / $200 / $250 / $350 / $400 / ·  Admission to all Scientific Sessions
·  Meeting Bag and Final Program
·  Free Access to Exhibition Area
·  Certificate of Attendance
·  Opening Ceremony & Welcome Reception
Speaker fee / $200 / $200 / $200 / $200
Residents / Fellows** / $125 / $150 / $175 / $200
Technician/Nurse*** / $125 / $150 / $175 / $200
Non Member / $450 / $500 / $550 / $600
Companions / $100 / $100 / $100 / $125 / ·  Free Access to Exhibition Area
·  Opening Ceremony & Welcome Reception
·  IMPORTANT: the registration fee does NOT include admission to the scientific sessions, Final Program or other congress documentation
TOTAL


* PAAO Active member. Ophthalmologist who pays annual membership fee to the PAAO. PLEASE NOTE: If you register as a PAAO Active Member, but are

not currently up on your dues, you will be billed for the current-year dues in addition to the registration fee.

** Residents / Fellows: Must show letter from the training Hospital verifying your residence or fellowship at time of registration, otherwise non-member fee will be charged.

*** Technicians and Nurses: Must show a letter from their employer verifying employment status.

CANCELLATION REFUND POLICY: Requests for cancellation and refund must be received in writing.

- Until December 31, 2014: full refund less $50 administrative fee per registration

- After January 1, 2015 to July 1, 2015: 50% refund

- After July 1, 2015: no refund

FORM OF PAYMENT Mark the corresponding box with an X

q Cash q Check payable to: Pan-American Association of Ophthalmology. (US BANKS ONLY)

q Credit card charge: TOTAL AMOUNT USD $

Charge will appear as Pan-American Association of Ophthalmology

Type of credit card: q Visa q Master Card q American Express q Discover Card

Card number:

Expiration Date ¨¨¨¨ Security Code ¨¨¨¨

month year Visa and M.C. a 3 digit number found in the back of the card

American Express a 4 digit number found in the center right of your card

Name of the card holder

Date: Signature of the cardholder

For Information contact: / Pan-American Association of Ophthalmology 1301 S. Bowen Road, Suite 450 Arlington, TX 76013 USA
Tel.: (817) 275-7553 / Fax: (817) 275-3961 / / www.paao.org