2019 Conference Delegate Registration – ONLINE PAYMENT Use the form below to register and pay ONLINE with credit card or paypal. For delegate registrations by OFFLINE payment methods, please click here to use this form. REGISTRANT INFORMATIONName* First Last Mailing 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 GrenadinesSaint MartinSamoaSan 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 Home or Work Phone*Personal Email* WORK INFORMATIONHospital*Site*Position*City*FULL REGISTRATIONFull Registration (EARLY BIRD: Closes July 31st, 2019)Please selectEarly Bird ($339.00)Full registration includes Friday, Saturday, Sunday and Awards Banquet - After July 31st, full registration for current members is $452.00- Late Registrations and Walk Ins welcomed after September 1st ($565.00)DAY DELEGATE REGISTRATIONDay DelegatePlease select date(s) Sat Sept 7th, 2019 Sun Sept 8th, 2019 AWARD BANQUETAdditional Banquet Tickets for Sat Sept 7th, 2019 Price: $ 85.00 CAD Quantity: PAYMENTAll fees include 13% HST (GST # 865266308 RC 0001) Please click the button below. You will be directed to Paypal where you can pay by credit card or your Paypal account.TOTAL (taxes included) $ 0.00 CAD Disclaimer / Waiver* I agree Participants by virtue of attending the MDRAO Conference, give their permission and consent to the Directors of the MDRAO to use their images or photographs or appear in videos or any other electronic or print media for advertising, news coverage, or any other commercial use of our event. Delegates’ name, hospital and email may be distributed to other conference delegates and exhibitors. This iframe contains the logic required to handle Ajax powered Gravity Forms.