ADVANCE REGISTRATION FORM AMERICAN CHEMICAL SOCIETY • 254th NATIONAL MEETING & EXPOSITION AUGUST 20 – 24, 2017 • WASHINGTON, D.C.
4 ways to register: (see Registration Procedures) Online: http://www.acs.org/dc2017 (credit cards only). Phone: 508-743-0192 or 800-251-8629, Monday - Friday, 9 AM to 5 PM EST (credit cards only) by August 24, 2017. Mail completed form with payment to: ACS Registration c/o CDS, 107 Waterhouse Road, Bourne, MA 02532 by July 10, 2017. Fax completed form with payment to: 508-743-9604 (credit cards only) by August 24, 2017.
REGISTRANT INFORMATION o Dr. o Prof. o Mr. o Ms.
o Mrs.
First Name Company/Institution/Agency Street Address City State/Province Phone Ext. Fax Emergency Contact Name
ACS Membership #_________________ (Required for member discount) Last Name
Title
Zip/Postal Code E-mail Address Emergency Contact Number
Country Cell Number
With your approval, ACS show management will be sending meeting alerts & special offers by text messaging. Regular text messaging rates may apply. q Yes I accept or q No I do not accept How would you like to receive your meeting announcements, networking connections, and exhibitor promotions before, during, and after the meeting? (check all that apply) q Mail q E-mail q Do not contact me Do you require special services or auxiliary aids in order to participate in the meeting?
q Yes q No Describe
DEMOGRAPHICS
SOCIAL EVENT FEES
1. Professional Affiliation (check one)
q (a) Academia q (b) Government q (c) Industry q (d) Student q (e) Other _____________________________________________________
8. W hat mode of transportation will you take to attend the meeting? q Plane q Train q Car q Other ____________________________________
2. Highest Degree Received (check one)
q (A) A.S./A.A.S. (Associate Degree) q (B) B.S./B.A. (Baccalaureate Degree) q (C) M.S. q (D) Ph.D. q (E) Still in school (degree not completed) q (F) Other _____________________________________________________
3. Professional Concentration (check all that apply) q (A) Aerospace/Transportation q (B) Agriculture & Food q (C) Analytical q (D) Biochemistry q (E) Biotechnology q (F) Chemical Education q (G) Chemical Information q (H) Clinical/Diagnostic q (I) Colloids & Surfaces q (J) Combinatorial Chemistry q (K) Computing/Molecular Modeling q (L) Electronics/Semiconductors q (M) Energy/Fuels q (N) Environmental q (O) Forensics q (P) Geochemistry q (Q) Glass/Ceramics/Composites q (R) Health & Safety q (KK) Other
q (S) Inorganic q (T) Law/Legal Affairs q (U) Lubricants/Oils q (V) Marketing/Sales/Business q (W) Materials q (X) Metals/Metal Products q (Y) Nuclear q (Z) Organic q (AA) Paint/Coatings q (BB) Personal Care/Cosmetics q (CC) Pharmaceutical/Medicinal q (DD) Physical q (EE) Polymers/Plastics q (FF) Pulp/Paper/Wood q (GG) Rubber q (HH) Soap/Detergent/Cleaners q (II) Textiles/Fiber q (JJ) Toxicology
4. Product Interest (check all that apply) q (A) Academic & Educational Svcs q (B) Accessible/Barrier-Free Products q (C) Analytical Research q (D) Business Mgmt & Service q (E) Career Development & Training q (F) Chemicals, Reagents & Raw Materials q (G) Laboratory Equipment & Svcs
q (H) R&D and Manufacturing Svcs q (I) Sci. Computing & Data Mgmt q (J) Technical Literature, Websites & Databases q (K) Testing & Measuring Instrumentation q (L) Other _______________________
5. Is this your first ACS National Meeting? q Yes q No 6. What’s your primary reason for attending this meeting?
q Present a paper or poster q Network with other scientists q Investigate research or technical topics q Research or buy products inside Exposition q Search for a job in Career Services q Obtain new skills and hands-on experience q Participate in ACS governance activities q Work during the meeting (staff/exhibitors) q Other_____________________________________________________________
7. Where are you staying (or planning to stay) during the meeting? Hotel _______________________________ Other _____________________
REGISTRATION CATEGORIES & FEES ACS Members
Early Standard
from May 22
ACS member or Society affiliate $445 Emeritus or retired $225 50-year No Fee Unemployed (dues waiver required) No Fee Graduate student $225 Undergraduate Student $110 Precollege teacher $110 One day member registrant $225 q Su q M q Tu q W q Th Non-Members q Chemical scientist $780 q Visitor: Non-chemical scientist $445 q Visitor: Chemical technician $445 q Graduate Student $445 q Undergraduate Student $225 q Pre-College Teacher $110 q One-day registrant $445 q Su q M q Tu q W q Th q Guest of Registrant (1) $45 q q q q q q q q
after July 10
$535 $270 No Fee No Fee $225 $110 $110 $270
$935 $535 $535 $445 $225 $110 $535 $45
(1) Guest Registration - A Spouse or family member of the registering attendee having no affiliation with the field of chemical science and is not eligible to become a member of the ACS. Only one guest registration allowed per full or one-day registration.
Guest Name _________________________________________ Exposition Visitors q Adult $60 $60 q Student $30 $30 9. Registration Subtotal $ ___________
Qty ____ ____ ____
$/Ticket ______ ______ ______
11. Social Event Subtotal
$ TOTAL _________ _________ _________ $ _________
If you register before the social event tickets are available, you can later purchase your tickets by contacting the Customer Service office, at 508-743-0192 or 1-800-251-8629, if you are paying by check or money. If you are paying by credit card, you can update your registration online by using your confirmation number.
ABSTRACT FEES ACS Member Non-Member Flash Drive (pick up) ____ @$65 ea. ____ @$90 ea. Flash Drive (ship) ____ @$73 ea. ____ @$98 ea.
12. Abstract Subtotal
$ _________
Abstracts ordered by July 10, 2017, will be shipped for delivery prior to the meeting. All other abstracts will be available for pickup onsite at Attendee Registration. ACS will not be responsible for abstracts not picked up during the meeting. Abstract flash drives will only be shipped to U.S. street addresses (no P.O. boxes)
GRAND TOTAL 13. Grand Total of 9-12
$ _________
Registrant Procedures: U.S. attendees who register by July 10, 2017, will receive their registration credentials and tickets via mail prior to the meeting. Unless an international attendee has provided a U.S. mailing address on their registration form, their credentials must be picked-up onsite at the Attendee Registration (this includes Canada and Mexico). After July 10, 2017, registrations will continue to be accepted at the standard rate on-line and by phone or fax (credit card payment only) until August 24, 2017. Registration Cancellation/Refund Policy: By adhering to the following cancellation procedure, cancellations received by July 31, 2017, are entitled to a full refund, less a $50 administrative fee. Registrants must return a copy of the registration confirmation along with the original registration credentials before payment will be posted to the account. All refunds are issued via the same method used for payment.
ADDITIONAL INFORMATION
PROGRAM BOOK FEE Early rate $10.00 (May 22, 2017 – July 10, 2017) Qty _______ Standard/Onsite rate $20.00 (July 11, 2017 – Aug 24, 2017) Qty _______ The hardcopy pricing of the Onsite Program includes an online version of the Author index that will be available 1 week before the meeting.
10. Program Book Subtotal
Event No. _________ _________ _________
$ _________
PAYMENT
Would you like add your twitter handle to be included on your registration badge? q yes or q no. Twitter handle: ______________________________________________ Are you an ACS Publications Author? q yes or q no Are you an ACS Publications Reviewer? q yes or q no If so, you will receive a pin with your registration.
You agree to accept all terms and conditions by submitting this registration to participate in the ACS National Meeting & Exposition.
Paid by: q Check - (made payable in U.S. dollars to American Chemical Society) Credit Card Type:
q VISA
q MasterCard
q American Express
q Diners
By signing below, the credit card holder agrees to pay the charges listed above in order to participate in the 254th ACS National Meeting in Washington, D.C.
Credit Card Number ______________________________________________________________ Exp Date ______________ Credit Card Billing Address & Zip ____________________________________________________________________________ Card Holder Name ______________________________________ Card Holder Signature _____________________________
The use of any device to capture images (e.g., cameras & camera phones) or sound (e.g., tape and digital recordings) or to stream, upload, or rebroadcast speakers or presentations is strictly prohibited at all official ACS meetings and events without express written consent from the ACS.
