Please enable JavaScript in your browser to complete this form. - Step 1 of 4REGISTRATION FORMWelcome to the registration page for AKMG Ottawa 2018. We are all set to welcome you all to the beautiful capital city of Canada. Come enjoy the feast and festivities. Registration amount per person covers all meals and entertainment. CME Fee is waived for AKMG Life Members This is a dynamic form and relevant fields will be available based on your responses. Please note that your registration type will be reflected in your badge.Select Participant Type *Physician/DentistTrainee (Medical School, Residency of Fellowship)Physicians/Dentists (Pre-License)#Industry PartnerExhibitorFor families please select the participant type for primary person registering. Guest registrations are not currently available. Physicians/Dentists should register separately unless they are spouses of the primary registrant. Trainees must register independently for special rates. Industry partners and exhibitors will need a separate invitation to validate registration. #Pre-License refers to physicians or dentists who have recently immigrated and are in the process of acquiring a license to practise. There are limits on the number of registrations from Industry partners and exhibitors, depending on the sponsorship level.Name *FirstMiddleLastI am a life member of AKMG.YesNoMedical or Dental School *Medical School / College of graduation (MBBS/MD)Year of Joining Medical School *Specialty or Subspecialty *Primary Hospital of Clinic Affiliation *Upload Document *Trainees may upload proof of current active trainees status. Pre-License physicians and dentists may upload a cover letter in pdf.NextEmail *EmailConfirm EmailEmail NewsletterI would like to receive email updates from AKMGHome Phone *Cell PhoneWe will add you to a conference whattsapp group for communications before and during the meeting.Cell PhoneTwitter HandleAddress *Address Line 1Address Line 2CityState / Province / RegionPostal CodeCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Province of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryDo you have any dietary restrictions? *NoYesDietary Request *VegetarianHalal (when meat not available, fish or vegetarian will be provided)OtherWe will try our best to accommodate this request. Choices may not be available with all menu selections. Food may contain allergens including nuts.Other Dietary RequestPreviousNextNumber of additional family members *Trainees register individually. MD/DDS, other than spouse, must register separately.0123456Total number of people registering and paying together in your party.Name of accompanying family member (FM2) *FirstMiddleLastEmailEmail Newsletter (copy)I would like to receive email updates from AKMGIs this registrant a practising physician or dentist? *YesNoI am a life member of AKMG. (FM2)YesNoCell Phone Please include your country code.The number will be used to add you to a conference whattsapp group to update you on the proceedings and for instant communications during the meeting. Medical or Dental School (Spouse) *Medical School / College of graduation (MBBS/MD)Year of Joining Medical School (Spouse) *Specialty or Subspecialty (Spouse) *Primary Hospital of Clinic Affiliation (Spouse) *FM2 dietary restrictions? *NoYesFM2 Dietary Request *VegetarianHalal (when meat not available, fish or vegetarian will be provided)OtherWe will try our best to accommodate this request. Choices may not be available with all menu selections. Food may contain allergens including nuts.FM2 Other Dietary RequestName of accompanying family member (FM3) *FirstMiddleLastFM3 dietary restrictions? *NoYesFM3 Dietary Request *VegetarianHalal (when meat not available, fish or vegetarian will be provided)OtherWe will try our best to accommodate this request. Choices may not be available with all menu selections. Food may contain allergens including nuts.FM3 Other Dietary RequestName of accompanying family member (FM4) *FirstMiddleLastFM4 dietary restrictions? *NoYesFM4 Dietary Request *VegetarianHalal (when meat not available, fish or vegetarian will be provided)OtherWe will try our best to accommodate this request. Choices may not be available with all menu selections. Food may contain allergens including nuts.FM4 Other Dietary RequestName of accompanying family member (FM5) *FirstMiddleLastFM5 dietary restrictions? *NoYesFM5 Dietary Request *VegetarianHalal (when meat not available, fish or vegetarian will be provided)OtherWe will try our best to accommodate this request. Choices may not be available with all menu selections. Food may contain allergens including nuts.FM5 Other Dietary RequestName of accompanying family member (FM6) *FirstMiddleLastFM6 dietary restrictions? *NoYesFM6 Dietary Request *VegetarianHalal (when meat not available, fish or vegetarian will be provided)OtherWe will try our best to accommodate this request. Choices may not be available with all menu selections. Food may contain allergens including nuts.FM6 Other Dietary RequestName of accompanying family member (FM7) *FirstMiddleLastFM7 dietary restrictions? *NoYesFM7 Dietary Request *VegetarianHalal (when meat not available, fish or vegetarian will be provided)OtherWe will try our best to accommodate this request. Choices may not be available with all menu selections. Food may contain allergens including nuts.FM7 Other Dietary RequestIndustry Partners and Exhibitors can skip this page.PreviousNextConfirm Dates Attending Convention *August 9August 10August 11Registration FeesWe are thankful to our generous sponsors who have helped make this convention a grand event. The total amount reflects the early bird registration cost and HST of 13%. The type of registration will be reflected in your badge.All meals including breakfast, lunch and dinner during the event is covered by the fees per person below. Please note, all fee categories except CME fees are applicable to life members of AKMG.CME ($50.00CAD) The fee is waived for AKMG Life Members, Speakers and Trainees *01234Please select 0 if you satisfy any of the following: Life Member of AKMG, Speaker or Trainee.Physician or Dentist ($500.00CAD +13% HST) *Number of MD/DDS012Total for each MD is 565.00Adult Family Member ($450.00CAD+13% HST) *Number of additional Non-MD adults with you0123456Total including HST for each additional person is 508.50 CADChildren (10-18 years old) ($350.00CAD+13% HST) *Number of kids012345Children (2-9 years old) ($300.00CAD+13% HST) *Number of kids012345Donate to our cause ($100.00 / Unit)Select units012345Dear AKMG family, you have already seen the efforts we have taken to bring you a grand event at the lowest possible cost. The intent is to encourage young families to attend the AKMG Convention and help build the future of the organization. We are requesting our generous membership who are willing to make a donation to our cause to kindly make a voluntary donation by purchasing units of $100.00 each. Each unit purchased will count towards a chance to win a major prize that will be announced at the gala night. All extra money collected in this manner will go towards a charitable cause that will be announced at the gala dinner. Trainee ($200 for students and $250+13% HST for residents/fellows/pre-license) *Select type of registrationMedical StudentResidentFellowPre-LicenseResidents and Fellows are current trainees. Please upload evidence for active trainee status. Pre-License refers to newly migrated physicians or dentists who have not yet started their advanced training and are not currently employed. Industry Partner / Exhibitor ($550.00CAD +13% HST) *012Total$ 0.00Total in Canadian DollarsCredit Card *Card NumberSecurity CodeName on CardExpirationMM123456789101112/YY2425262728293031323334Comments or QuestionsIndustry Partners and ExhibitorsCaptcha * Please enter the fourth letter of the english alphabet in the box below. Captcha helps identify you as human. This is to avoid bots from registering. Please enter 'D' in the box above. PreviousEmailSubmit