2014 APPA Meeting Registration Question Title * 1. Name (Last, First) Last name First name Question Title * 2. Degree Question Title * 3. Institution Name Question Title * 4. Institution Address Building or Building number Room or Department City State Country Postal Code Question Title * 5. Is this address in the United States? Yes No Question Title * 6. Daytime phone number (if non-US include country and city code) Question Title * 7. Email Address Question Title * 8. If APPA member, are you paying 2014 dues with registration? APPA Fellow or Member paying $150 dues APPA Lifetime Member paying $50 dues APPA member not paying dues at this time Not APPA member Question Title * 9. 2014 Meeting Registration Non-APPA Member Registration $550 (before 12/31/13) APPA Member/Fellow Registration $300 (before 12/31/13) Student Registration $240 (before 12/31/13) Non-APPA Member Registration $660 (1/1/14-2/15/14) APPA Member/Fellow Registration $360 (1/1/14-2/15/14) Student Registration $290 (1/1/14-2/15/14) Non-APPA Member Registration $760 (2/16/14-3/1/14) APPA Member/Fellow Registration $440 (2/16/14-3/1/14) Student Registration $310 (2/16/14-3/1/14) Question Title * 10. Will you be staying in the Grand Hyatt Hotel for one or more nights? No Yes Question Title * 11. Are you a resident of the New York Metro Area, commuting to the meeting? Yes (Please add NY Metro Advantage fee of $100, unless you are registering as student) No Question Title * 12. Will the payment be made by the Registrant or by someone else (a department, foundation or administrator for the registrant)? Registrant will make payment Other payer Other (please specify) Question Title * 13. Payment of Dues + Registration + Surcharge (if applicable) Paypal (www.appassn.org/pay.html) Fax credit card information (www.appassn.org/creditcard.pdf) to 212-995-4018 c/o PE Shrout Emailing scanned credit card info (www.appassn.org/creditcard.pdf) to appaassn@gmail.com Mailing check to PE Shrout, 39 Marion Road, Montclair NJ 07043 Done