October 28-30, 2018 | Vancouver, BC
American Academy of Periodontology
HOW TO REGISTER
Please complete all applicable sections (one professional registrant per form) prior to submitting the registration form. Forms submitted without payment information will not be processed. Checks drawn on a U.S. bank in U.S. dollars made payable to the American Academy of Periodontology, or credit card (Visa, MasterCard, Discover, or American Express only) are acceptable forms of payment. In order to receive the member rate, 2018 membership dues must be paid prior to registration.
Registration forms must be received by 11:59 p.m. EST on March 30, 2018, for the early-bird Vancouver pricing. Confirmations will be emailed to the email address provided; allow 72 hours for receipt. If you do not receive your information within this time period, call Experient at 800-424-5249 (U.S. participants) or +1-847-996-5829 (international participants).
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 Emergency Contact (mandatory) o DDS o DMD o RDH o Other (specify)
State Fax
Postal Code Email
Country (other than USA) Phone Demographic Information: o Male o Female | Years in practice: o 0-5 years o 6-10 years o 11-15 years o 16-20 years o 21+ years
SECTION A: Registration Categories (select one) Please note: All registration fees are in U.S. dollars
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 o RG13: Office Staff
o RG14: Spouse/Guest Name:
o RG15: Insurance Workshops Only (must register for at least 1 IW) o RG16: JACP/JSP Member
o RG17: JACP/JSP Student Member o RG18: JACP/JSP Dental Hygienist o RG19: JACP/JSP Office Staff o RG20: CAP Member
o RG21: CAP Student Member o RG22: CAP Dental Hygienist o RG23: CAP Office Staff
o RG25: Corporate Forum Registration o RG29: Dental Hygiene Symposium Only
SECTION A: Registration Categories Total
Early Bird Advance $704 $704 $704 $704 $394 $205
$819 $819 $819 $819 $499 $310
Early Bird Advance $1,425
$1,274 $63
$316 $428 $428
$132
$1,542 $1,391 $89
$423 $551 $551
$132
$819 $310 $551 $551 $819 $310 $551 $551
On Site $924 $924 $924 $924 $614 $415
Complimentary (only available to Active/Life Active members)
On Site $1,660
$1,509 $116
$642 $665 $665
$132
Course fees shown in SECTION C $704 $205 $428 $428 $704 $205 $428 $428
$924 $415 $665 $665 $924 $415 $665 $665
Complimentary (no access to any other portion of meeting)
Course fees (must register for EV3) $ Arrival Date _____/_____ /_____ Departure Date _____/_____ /_____
Rank hotels (1 to 8) by preference and check occupancy for each (one room per professional registrant). A credit card guarantee is necessary at the time of booking (expiration date of 10/18 or later). Experient will forward the credit card information to your hotel. The hotel will charge a one night’s room and tax deposit to the credit card upon receipt of the reservation data in September 2018. Rates below are inclusive of a CAD$17 per room per night rebate to Experient.
___ Fairmont Waterfront (Co-Headquarters) City View Room o CAD$260 Single o CAD$260 Double o CAD$290 Triple o CAD$320 Quad
___ Pan Pacific (Co-Headquarters) Deluxe Room o CAD$275 Single o CAD$275 Double o CAD$295 Triple o CAD$315 Quad
___ Coast Coal Harbour Hotel Standard Room o CAD$215 Single o CAD$215 Double
___ Fairmont Pacific Rim Run of House o CAD$335 Single o CAD$335 Double o CAD$365 Triple o CAD$395 Quad
___ Four Seasons Run of House o CAD$246 Single o CAD$246 Double o CAD$286 Triple
___ Hyatt Regency Vancouver Standard Room o CAD$244 Single o CAD$244 Double o CAD$279 Triple o CAD$314 Quad
___ Marriott Pinnacle Downtown City View Room o CAD$279 Single o CAD$279 Double o CAD$309 Triple o CAD$339 Quad
___ Pinnacle Hotel Harbourfront Run of House o CAD$279 Single o CAD$279 Double o CAD$309 Triple o CAD$339 Quad
o I plan to share with (full name): ________________________________ oNo hotel reservation needed.
If staying outside the AAP room block, indicate hotel: __________________ Special needs: o Audio o Visual o Mobile o Other: __________________
o Check here if you are an ABP Diplomate o Check here if you are a first-time attendee
n Online (preferred method)
members.perio.org/am2018 n Mail (check or credit card)
Experient/AAP Annual Meetings 2018 5202 Presidents Court, Suite G100 Frederick, MD 21703
n Fax (credit card) 301-694-5124
n Phone (credit card) 800-424-5249
(U.S. participants) +1-847-996-5829 (international participants)
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.
Housing and Registration Form
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