2016 AGC-Chicago Registration Form (1 form per member)
Name: ________________________________________ Class: _________ Specialty: __________________
Billing Address: _____________________________________________________________________________
________________________________________________________________________________________________
Mailing Address: ____________________________________________________________________________
________________________________________________________________________________________________
Cell phone: ____________________________ ( ) Home ( ) work/others: ______________________
E-mail address (to confirm receipt): _____________________________________________
Payment method:
( ) Check enclosed , pay to UPMASA Chicago
( ) Credit Card (Visa/MC only)
Number: ___________________________________ Exp date: __________ Code: _________
Attending with the following family members (please give names and relationship)
Seating preference, we will try to honor requests: ( ) with class ______
( ) with Chapter _____________________
Postmarked/online payment by
15-May
15-Jun
on
site
Table 1: Full Package- Welcome Reception/Pabidahan, Alumni Luncheon, CME, Gala Dinner and
Celebration, Farewell Brunch
Lifetime member & regular member with paid dues 2016
Regular member with unpaid dues 2016
Retired member with paid dues or Guest . Full package without CME
Retired member with unpaid dues, Full package without CME
Residents/Fellows with letter from Program Directory
$535
635
$595
695
$655
755
425
525
300
485
585
340
545
645
380
Table 2: Additional Event Purchases for immediate family members with 1 purchase of Full Event
above
July 13 Wednesday Welcome Reception
130
150
170
July 14 Thursday Alumni Luncheon
30
40
50
July 15 Friday Gala Dinner and Celebration
180
200
220
July 16 Saturday Farewell Brunch at 9AM
85
95
105
July 14 & 15 Thursday and Friday CME (w/ continental breakfast)
110
110
110
Table 3: A la carte Purchases of Individual Events (add Membership fee if unpaid at time of
purchase)
July 13 Wednesday Welcome Reception
140
160
July 14 Thursday Alumni Luncheon
35
45
July 15 Friday Gala Dinner and Celebration
200
220
July 16 Saturday Farewell Brunch
90
100
July 14 & 15 Thursday and Friday CME (with continental breakfast)
120
120
180
55
230
110
120
Table 4: *Optional Events (Not part of Full Package)
July 12 Tuesday: Golf (contact: Rudy Lacuesta 847-644-0251)
July 12 Tuesday: Tennis (contact: Francis Almeda 312-593-1994)
July 15 Friday Lunch Meeting: Frat/Sorority -Mu Sigma Phi
July 15 Friday Lunch Meeting: Frat/Sorority - Phi Kappa Mu
*Convenience Fee if purchasing only Optional Events
120
60
75
75
25
130
60
85
85
25
140
60
100
100
25
100
20
140
120
25
160
136
30
170
Table 5: Membership fees
Lifetime Membership - S400; Retired Lifetime - $200; Annual Fee - $100
Table 6: Discounted individual Events for Residents & Fellows
July 13 Wednesday Welcome Reception
July 14 Thursday Alumni Luncheon
July 15 Friday Gala Night
Quantity
Total
July 16 Saturday Farewell Brunch
July 14 & 15 Thursday and Friday CME (with continental breakfast)
60
0
75
0
80
0
GRAND TOTAL
Mail Completed form to:
UPMASA c/o Susan Echiverri MD
3s161 Williams Road
Warrenville, IL 60555