First Name:                                                                                                  

Last Name:

AMA # (MUST be a current AMA member to participate):

Frequency Requested:  (Limited to 2 flyers per frequency)

                        Primary Choice?                           Secondary Choice?

Billing Address:

Apt.:

City:                                                                                                         State:

Zip/Postal Code:                                                                       Country:

E-mail Address:

Phone Number:  (     -     -     )     _     _     _     --     _     _     _     _

Registration fee is $20 US and includes both days registration and lunch both days.  If using a check, 

make payable to SASS.

Payment Type:  Check or Money Order