Register

Registration

Types of Tickets

Full Conference $350

All lectures taking place from Friday, January 10th - Sunday, January 12th. Includes complimentary cocktail hour on Friday evening, continental breakfast and lunch on Saturday, and continental breakfast on Sunday.

Sunday Only $150

Continental breakfast, Medical Errors & Jurisprudence lectures on Sunday, January 12th.

Attendees

Number of Attendees

Attendee #1

Ticket Type

Attendee Name*

First Last

Attendee Phone*

Attendee Email*

Attendee Designation*

Attendee Practice Name

Attendee's Primary State License*

Check box if your mailing address & billing address are the same.

yes

Attendee Address*

This is where the TQ exams will be sent.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Attendee #2

Attendee #2 Ticket Type

Attendee #2 Name

Prefix First Last Suffix

Attendee #2 Phone

Attendee #2 Email

Attendee #2 Designation

Attendee #2 Practice Name

Attendee #2 Primary Licensed State

Attendee #2 Address

Street Address Address Line 2 City State ZIP Code

Attendee #3

Attendee #3 Ticket Type

Attendee #3 Name

Prefix First Last Suffix

Attendee #3 Phone

Attendee #3 Email

Attendee #3 Designation

Attendee #3 Practice Name

Attendee #3 Primary Licensed State

Attendee #3 Address

Street Address Address Line 2 City State ZIP Code

Attendee #4

Attendee #4 Ticket Type

Attendee #4 Name

Prefix First Last Suffix

Attendee #4 Phone

Attendee #4 Email

Attendee #4 Designation

Attendee #4 Practice Name

Attendee #4 Primary Licensed State

Attendee #4 Address

Street Address Address Line 2 City State ZIP Code

Attendee #5

Attendee #5 Ticket Type

Attendee #5 Name

Prefix First Last Suffix

Attendee #5 Phone

Attendee #5 Email

Attendee #5 Designation

Attendee #5 Practice Name

Attendee #5 Primary Licensed State

Attendee #5 Address

Street Address Address Line 2 City State ZIP Code

Billing Information

Coupon

Promotion

Total

$0.00

Billing Email*

What email would you like to receive billing receipt to?

Billing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Registration

Attendee #1

Attendee #2

Attendee #3

Attendee #4

Attendee #5

Billing Information

About CE Sarasota

Additional Information

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