New York ACEP Website

New York ACEP

Emergency Medicine Continuous Certification Registration Form

Lifelong Learning and Self-Assessment (Schedule Below)

Registrant Information:

First Name: Last Name:

Credentials: MD DO FACEP Other

Is Mailing Address below Home or Work? Home Work

Institution/Hospital:

Department:

Street:

City: State: Zip:

Daytime Telephone: Extension:

Fax:

E-mail:

For your name badge- Institution:

For your name badge- City, State:

Registration is limited! Your form and payment must be received at least one week prior to course date.

Select course location:

2008 Article Review Sessions

March 20, 2009 -SUNY Upstate Medical University

Fees: (Add $35 to each registration category when registering within 14 days of course)
ACEP Member
Course plus on-site testing	$199
Course, on-site testing and photocopied articles (excludes JAMA articles)	$225
visit www.jama.com for access options
Non-Member
Course plus on-site testing	$275
Course, on-site testing and photocopied articles (excludes JAMA articles)	$300
visit www.jama.com for access options

ABEM's Lifelong Learning and Self-Assessment Test Fee is $95.

Payment Information:

Payment Method: Visa MasterCard American Express Check

Credit Card Number: Expiration Date:

Name as appears on card:

Zip Code for credit card billing address:

If paying by check, make payable to New York ACEP and return at least one week prior to course date: New York ACEP, 1070 Sibley Tower, Rochester, NY 14604. A credit card number must be entered to reserve your registration.

Registration can also be taken by phone (585-546-7241) or fax (585-546-5141).