Title*
First Name:*
Middle Name:
Last Name:*
Address:*
City:*
Province:*
Postal Code:*
Phone:*
Fax:
Email Address:*
Application Mmembership:*
Number of Tickets x $100.00 Each:
May we include your contact info in the distributed list to attendees?*
Please advise of any dietary allergies or concerns:
Credit Card Type:*
Credit Card Number:*
Name on Credit Card:*
Expiry Month:*
Expiry Year:*

Applicant Information
Title*	--------Select------------- Dr. Ms. Mrs. Miss Mr.
First Name:*
Middle Name:
Last Name:*
Address:*
City:*
Province:*
Postal Code:*
Phone:*
Fax:
Email Address:*
Registration Type
Please check appropriate rate
Regular Registration Late Registration (After Sept 15/11) CSAM Member, Physician CSAM Member, Associate CSAM Member, Student Non Member, Physician Non Member, Non-Physician Non Member, Student One – Day registration $500 $600 $250 $325 $100 $150 $600 $700 $350 $425 $150 $200 $250 $350
President's Banquet Dinner Tickets
Number of Tickets x $100.00 Each:
President's Banquet held:	November 4, 2011
Attendee Information
May we include your contact info in the distributed list to attendees?*	--------Select------------- Yes No
Please advise of any dietary allergies or concerns:
Cancellation Policy
All written notice of cancellation prior to Oct 01/2011 will be refunded minus a $50 processing fee. No refunds after Oct 15 / 2011will be accepted.
Payment Information
Credit Card Type:*	VISA  MasterCard
Credit Card Number:*
Name on Credit Card:*
Expiry Month:*	--------Select------------- 01 02 03 04 05 06 07 08 09 10 11 12
Expiry Year:*	--------Select------------- 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031

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