Housing and Registration Form HOW TO REGISTER


Please complete all applicable sections (one registrant per form) prior to submitting. Forms submitted without payment information will not be processed. Checks drawn on a U.S. bank in U.S. dollars or credit card (Visa, MasterCard, or American Express) are acceptable forms of payment. In order to receive the member rate, 2017 membership dues must be paid prior to registration.


Registration forms must be received by 11:59 p.m. ET on March 31, 2017 for early-bird pricing. Confirmations will be emailed; allow 72 hours for receipt. Contact Experient at 800-424-5249 or 847-996-5829 if you do not receive your information within this time period.


Online (preferred method): perio.org/meetings


Mail (check or credit card): Experient/AAP Annual Meetings 2017


5202 Presidents Court, Suite G100 Frederick, MD 21703


PERSONAL INFORMATION City and state will be printed on your badge. AAP Membership # ____________________________________ (Required for Members) First Name


Last Name Call Name for Badge


Address City


Phone


o Check here if you are an ABP Diplomate o Check here if you are a first-time attendee


Demographic Information: o Male o Female


SECTION A: REGISTRATION CATEGORIES (select one)


MEMBERS o RG01 Active Member o RG02 Associate Member o RG03 International Member o RG04 Life Active Member o RG05 Retired Member o RG06 Student Member


o RG07 General Assembly Only (no meeting participation)


NON-MEMBERS/OTHER o RG08 Non-member Dentist/Periodontist


o RG09 Sponsored Non-member Dentist/Periodontist Sponsor Code:


o RG10 Dental Student Interest Group (DSIG) o RG11 Non-member Student


o RG12 Dental Hygienist/Full Conference o RG14 Office Staff


o RG15 Spouse/Guest Name:


o RG16 Dental Hygiene Symposium Only o RG17 Insurance Workshops Only


o RG19 AAP/AAPF/Osteology Foundation Third-Year Resident o RG20 Corporate Forum Registration


o RG22 Student Exhibits Only Registration (Tuesday on-site only and must present a valid Student I.D.)


o DDS o DMD o RDH o Other (specify)


State Fax


Postal Code


Country (other than US) Email


o AAP recognizes the need to comply with the Americans with Disabilities Act. Please check here if you have special needs. An Experient staff member will contact you regarding your requirements.


EMERGENCY CONTACT INFORMATION (mandatory): Emergency Contact_____


Early Bird Advance March 31)


(after


$704 $704 $704 $704 $394 $205


$819 $819 $819 $819 $499 $310


Years in practice: o 0-5 years o 6-10 years o 11-15 years o 16-20 years o 21+ years Contact Phone _____


SECTION B: HOUSING On-Site


$924 $924 $924 $924 $614 $415


Complimentary (only available to Active/Life Active Members)


$1411 $1261 $63


$313 $424 $424


$131


$1527 $1377 $89


$419 $546 $546


$131


$1644 $1494 $116


$636 $658 $658


$131 Course fees (must register for EV1)


Course fees (must register for at least one IW)


Complimentary (with appropriate documentation)


Complimentary (no access to any other portion of meeting)


N/A N/A SECTION A: REGISTRATION CATEGORIES TOTAL $ $25 Arrival Date _____/_____ /_____ Departure Date _____/_____ /_____


Rank hotels (1 to 7) by preference and check occupancy for each (one room per professional registrant). A credit card guarantee is necessary at the time of booking. Experient will forward the credit card information to your hotel. The hotel will charge one night’s room and tax deposit to the credit card in August 2017. Rates are inclusive of a $13 per room per night fee to Experient.


___ Westin Boston Waterfront (Headquarters) Standard Room o $283 Single o $283 Double o $308 Triple o $328 Quad


___ YOTEL Boston o $269 Single o $269 Double


___ Aloft Boston Seaport Standard Room o $261 Single o $261 Double o $281 Triple o $301 Quad


___ Element Boston Seaport Standard Room o $261 Single o $261 Double o $281 Triple o $301 Quad


___ Omni Parker House Standard Room o $275 Single o $275 Double o $295 Triple o $315 Quad


___ Renaissance Boston Waterfront Hotel o $312 Standard Single o $312 Standard Double o $325 Standard Triple o $325 Standard Quad


___ Seaport Hotel and World Trade Center Run of House Room* o $303 Single o $303 Double o $328 Triple o $353 Quad *Seaport charges additional service and hotel fees


o I plan to share with (full name): ________________________________ o No hotel reservation needed.


If staying outside the AAP room block, indicate hotel: __________________ Special needs: o Audio o Visual o Mobile o Other: __________________


SECTION B: HOUSING TOTAL $ Fax (credit card): 301-694-5124


Phone (credit card): 800-424-5249 (U.S. participants) +1-847-996-5829 (international participants)


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