CO ACEP Registration Form Personal Information First Name * Last Name * Email * Address Address Line 1 Line 1 Line 2 Line 2 City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Events Leadership Symposium, November 2nd, 1pm -5pm Leadership Symposium, November 2nd, 1pm -5pm CO ACEP Member – $150 Non-CO ACEP Member – $200 High Risk – Do Not Miss, November 3rd, 8am – 5pm Choose between full day, morning lectures only, or ultra sound skills only. Full Day Full Day, CO ACEP Member – $350 Full Day Non-CO ACEP Member – $500 Full Day Resident/Student – $250 Full Day, APP – $500 Morning Lectures ONLY Morning Lectures Only, CO ACEP Member – $100 Morning Lectures Only, Non CO ACEP Member – $200 Morning Lectures Only, Resident/Student – $100 Morning Lectures Only, APP – $200 Ultra Sound Skills ONLY Ultra Sound Skills Only CO ACEP Member – $250 Ultra Sound Skills Only, Non-ACEP member – $350 Ultra Sound Skills Only, Resident/Student – $150 Ultra Sound Skills Only, APP – $350 Payment Total $ First Name on Card * Last Name on Card * Billing Address * Billing Address Line 1 Line 1 Line 2 Line 2 City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Payment If you are human, leave this field blank. Submit
