2019 EFMD GN Americas Annual Conference"Embracing Life-Long Impact" Miami, Florida USA 20-22 November 2019Personal information:Name* DrMrMrsMsProf. Title First Last Position*College/Department/FacultyCompany/University*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Email* Telephone (Int'l)*Purchase orderMy portraitAccepted file types: jpg, jpeg.Please attach your photo in JPG format (full face portrait; 5MB max.). The photo will be added to the participants' list to facilitate networking.Registration status:I am:*full memberaffiliated/associated membernon-memberPrice:(early-bird fee applied)(late fee applied)as full member Price: $900.00 as affiliated/associated member Price: $1,000.00 as non-member Price: $1,100.00 Voucher Catering:Welcome Dinner*YesNoGala Dinner*YesNoI am allergic toalmondsblueberriesboletus mushroomchivesfigshazelnutsshellfishotherPlease specify 'other':*Dietary requirementsno dairy productsno fishno glutenno meatno nutsno porkno shellfishveganvegetarianotherPlease specify 'other':*Accompanying person social events*YesNoAccompanying person* DrMrMrsMsProf. Title First name Last name This person will attend:Welcome Dinner (+120 USD)yesnoGala Dinner (+125 USD)yesnoCatering accompanying person:Allergic toalmondsblueberriesboletus mushroomchivesfigshazelnutsshellfishotherPlease specify 'other':*Dietary requirementsno dairy productsno fishno glutenno meatno nutsno porkno shellfishveganvegetarianotherPlease specify 'other':*Welcome Dinner Price: $120.00 Gala Dinner Price: $125.00 Grand total:Total sum to pay: $0.00 Payment method*Bank transferCredit CardYou will find the bank details in the confirmation e-mail you will receive from the system.A pro-forma invoice (PDF) will be sent to the e-mail address you have entered above.Your credit card data is NOT stored as part of the form entry and is not retained by our site, server, or database. It only traverses (in a secure way, via SSL) our webserver and is transmitted to our payment processor (Stripe Inc.). It includes integrated card type detection so you don't have to pick which type of card you're using and it also has built-in validation to validate that the card format is correct.Credit Card Card Details Cardholder Name As soon as we have received your payment, we will issue the invoice.General:The fees cover attendance to the meeting, documentation, meals and refreshments, but NOT hotel accommodations.CANCELLATION POLICY: cancellations must be confirmed in writing by 21 October 2019. A cancellation fee of 75$ will be charged. Thereafter we are unable to refund any fees. However, in such cases, substitutes are welcome at no extra cost as long as we receive notification of the name, title and address of the substitute.Do you want to register a second person from the same Company/Institution?Additional registration*NoYesA new form will open after submission so that a second person can register.Technical information:Unique IDDate Date Format: MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.