ADA 137TH ANNUAL MEETING OCTOBER 19-23-207 1 Personal Info2 ADA Member/ADA Spouse/Guest3 Social Functions4 Payment Method REGISTRATION FOR THE MEETING DOES NOT RESERVE A HOTEL ROOM. Name*Phone*Email* Spouse/Partner Email* Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country ADA Member Registered by September 19, 2017 - $645 Registered by October 9, 2017 - $795 Registered after October 9,, 2017 - $1,000 ADA Member Registered by September 19, 2017 - $645 Registered by October 9, 2017 - $795 Registered after October 9,, 2017 - $1,000 Includes: Breakfasts, Opening Reception, joint session with ADA members, Literary Discussion, Dinner Honoring New Members, President’s Dinner and Farewell Breakfast Buffet Date ADA Member Fee Price: $645.00 Registered by September 19, 2017ADA Member Fee Price: $795.00 Registered by October 9, 2017ADA Member Fee Price: $1,000.00 Registered after October 9, 2017Spouse/Partner RECEIVING CMESelect hereSpouse/Partner $645.00NoneRegistered by September 19, 2017Spouse/Partner RECEIVING CMESelect hereSpouse/Partner $645.00NoneRegistered by September 19, 2017Spouse/Partner RECEIVING CMESelect hereSpouse/Partner $795.00NoneRegistered by October 9, 2017ADA Spouse/GuestSelect hereSpouse/Guest $445.00NoneRegistered by September 7, 2017ADA Spouse/Guest*Select hereSpouse/Guest $595.00NoneRegistered by October 7, 2017ADA Spouse/GuestSelect hereSpouse/Guest $795.00NoneRegistered by October 7, 2017Children$200/childNoIncludes: Breakfasts and Opening Reception onlyNo of children*Name(s) of Accompanying Child/Children (Must be registered above)* MEMBER T-SHIRT: GenderMaleFemaleT-shirt SizeSMLXLXXL GUEST T-SHIRT GenderMaleFemaleT-shirt SizeSMLXLXXL Social Functions FEE: No additional charge if registered for the meeting, however you MUST reserve for each event. Thursday, October 20 Breakfast Honoring New Members (8:00 AM) No of Attendees Saturday, October 22 President’s Cocktail Reception and Dinner (6:00 PM) No of AttendeesIndicate menu choice for each attendee: Beef Chicken Vegetarian Sunday, October 23 Farewell Breakfast Buffet (Served from 8:00 – 9:30 AM) No of Attendees Optional Tours Thursday, OctoberNo of AttendeesFriday, OctoberNo of Attendees Saturday, October Book Club (9:30 AM) No fee; indicate # of people No of AttendeesTotal $0.00 Payment Method Complete the information below and FAX to: (954) 252-2093 OR MAIL to: ADA, PO Box 551301, Davie, FL 33355 This page is unsecured. Do not enter a real credit card number! Use this field only for testing purposes. Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Expiration Date Security Code Cardholder Name This iframe contains the logic required to handle AJAX powered Gravity Forms.