Registration Form

* Name (Last, First, MI):

* Company Name:

* Office Phone:

Fax:

* Email Address:

* Confirm Email Address:

* Mailing Address:

* City:

* State/Province:

* Zip Code:

* Country:

Accompany Person(s) Name(s):
(include age if child)

 Age
Age

Registration Fees (select one per registrant): Includes all Breakfasts, Social Functions and Coffee Breaks
Up to 1 Nov After 1 Nov After 15 Jan FEES
Physician

$495.00

$550.00

$600.00
 $
Physician Hawaii (Kama'aina) +

$300.00

$350.00

$500.00
 $
Physician Dermatology Resident +

$200.00

$250.00

$300.00
 $
+ Proof Required
Physician / One (1) day pass

$200.00
 Note: On-site add $25.00 $
Physician / Two (2) day pass
(must be two consecutive days)

$300.00
 Note: On-site add $25.00 $
Date(s): /
R.N P.A. Office Personnel
Note: Must be accompanied by a physician

$300.00

$350.00

$400.00
 $
Spouses / Guests

$200.00

$250.00

$300.00
 $
Children over age of 10

$150.00

$200.00

$250.00
 $
Children under age of 10 Complimentary
Exhibitor-Additional 2nd or 3rd person/each

$300.00

$300.00

$350.00
 $

Workshops:  

ADVANCE REGISTRATION REQUIRED / NO FEE *

Will Attend
Treating Actinic Keratoses with 5-Flurouracil in Combination with 70% Glycolic Acid Peels (Tue., 2/26, 2:30–4:00P) Yes
Dermoscopy (Wed., 2/27 – 2:30–4:30P) Yes
Laser Workshop (Fri., 2/29 – 2:00–5:00P) Yes
Botulinum Toxin A and Fillers (Sat., 3/1 – 1:30–5:00P) Yes

* Due to industry support, the workshop fees have been waived.

Due to industry support the workshop fees have been waived. Advance Registration Required.
REGISTER EARLY. Workshop space is limited based on first-come, first served basis. On-site subject to availability.
NOTE: Maui Derm reserves the right to cancel any workshop for lack of attendance.
* Proof required for Kama’aina and Dermatology Residents.

Lunch with Faculty:  

Lunch with Faculty is hosted daily throughout the Conference at no additional charge. Registration Is Required. Please check below the dates on which you plan to attend.

Tues
 Weds

Thurs

Fri

Sat

Payment Information:  

Cardholder Name:

Payment Type:

Card Number:

Card Expiration Date:

CID:

Payment Amount:

 $

Make Checks Payable To:

 HTC INTL

Send To:

 HTC INTL
333 N. Michigan Ave.
Chicago, IL 60601



ACMD Administrative Office
41 E. Lipoa Street, Suite #21
Kihei, Maui, HI 96753
Email: information.services@acmd-derm-hawaii.com

©2007 ACMD, HTC International