UAPD 2019 Fall CME & Membership Meeting Registration

What is your role within UAPD?*

Board Member (UAPD, SEPA, or Retiree)
UAPD Staff Member or Special Invitee
UAPD Steward or Bargaining Team Member
Regular UAPD Member

UAPD pays transportation and Friday and Saturday night hotel costs for Board Members, UAPD Staff Members, and Special Invitees. All other UAPD members are responsible for their own travel and lodging costs.

Name*

First Last

Where do you work?

Your Degree(s)

M.D.
D.D.S.
D.O.
D.P.M
N.P.
P.A.
Pharm.D

Home Address

Street Address City State / Province / Region ZIP / Postal Code

Phone Number

Phone Number Type

Cell
Home

Personal Email

On Friday I Will Attend:

Pre-Meeting Dinner (Friday, October 25 from 6 pm to 7 pm)
UAPD/SEPA Board Meetings (Friday, October 25 starting at 7 pm)

I Will Attend the Following Events on Saturday:

Free CME/CE Class (Saturday, October 26 from 8:30 am to 12:30 pm)
Membership Meeting & Breakout Sessions (Saturday, October 26 from 2:00 pm to 4:30 pm)

What is Your Medical/Dental License Number?

Which Membership Meeting Will You Be Attending?

Saturday Lunch Choice:

Meat
Poultry
Vegetarian
Vegan/Gluten Free

Hotel and Transportation

Will You Require Accommodations at the Sir Francis Drake Hotel?

UAPD pays hotel room costs for Friday, October 25 and Saturday, October 26 for Board Members, UAPD Staff Members, and Special Invitees. All other UAPD members are responsible for their own hotel costs.

To reserve a room at the Sir Francis Drake at the special rate of $199+tax/night, you must provide your credit card information to UAPD. How would you like to proceed?

I will call UAPD at 1-800-585-6977 to provide my credit card number
I would like a UAPD staff member to call me for my credit card number
I will fax my name, credit card number, and expiration date to 1-916-446-3827

Check In Date

Check Out Date

Single or Double Occupancy?

Name of Additional Guest

One or Two Beds?

Other Hotel Information

NOTE: You must provide your credit card information to UAPD to complete your room reservation. How would you like to proceed?

I will call UAPD at 1-800-585-6977 to provide my credit card number
I would like a UAPD staff member to call me for my credit card number
I will fax my name, credit card number, and expiration date to 1-916-446-3827

Because of the costs associated with no-shows, UAPD now requires that members provide a credit card number whenever a hotel room is reserved in their name. If you cannot attend the meeting, you must notify UAPD (1-800-585-6977) prior to October 18th so that your hotel room can be canceled. Failure to do so may result in your credit card being charged the room rate for one night.

Will you be flying to the event?

UAPD pays transportation costs for Stewards, County/Clinic Bargaining Team Members, Board Members, UAPD Staff Members, and Invited Guests.

I wish to depart from/return to (airport):

I wish to fly to San Francisco on (date):

Preferred Departure Time:

:

I wish to return home on (date):

Preferred Return Time:

:

Will you need car parking for the meeting?

Anything Else We Should Know?

UAPD 2019 Fall CME & Membership Meeting Registration

Hotel and Transportation

ADDRESS

PHONE

Email