Institutional Membership Form Please indicate your level of institutional membership:*Platinum Member: $15,000 Educational GrantGold Member: $10,000 Educational GrantSilver Member: $5,000 Educational GrantBronze Member: $2,500 Educational Grant -Promote your institution through a 30-60 second video to be shown outside the main session -Receive 4 free full conference registrations ($2,400 value) -PLUS: Free attendance for 3 to the Surgical Investigators Course ($900 value) -Receive 3 free full conference registrations ($1,800 value) -PLUS: Free attendance for 2 to the Surgical Investigators Course ($600 value) -Receive 2 free full conference registrations ($1,800 value) -PLUS: Free attendance for 1 to the Surgical Investigators Course ($300 value) -Receive 1 free full conference registration ($600 value) Payment Options – I would like to*Payment deadline: January 11, 2019Pay NowPay later with check or a wire transferTotal $0.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name Institution*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Pre-Meeting Logistics ContactThis individual will be responsible for the following: -Payment for institutional membership -Provide Institutional LOGO -Provide Institutional VIDEO (Platinum only) -Provide Institutional blurb for meeting app -Distribute discount code among those selected from your institution to receive free registration(s) and ensure they are used. -Provide the name and contact info for the Institutional Rep who will receive the plaque at the Opening Session on behalf of your institution. Pre-Meeting Logistics Contact Name* First Middle Last Pre-Meeting Logistics Contact Phone*Pre-Meeting Logistics Contact Email* Department Chair Name* First Middle Last Department Chair Phone*Department Contact Email* Institutional RepresentativePlease list the name and institutional title for the individual who will represent your institution at the Opening Session. Instructions regarding their participation in the Opening Session will be sent separately. If you do not know who will serve as your institutional representative now, you will have the option to provide it via the link to be included in your confirmation email. DEADLINE: JANUARY 11, 2019Institutional Representative Name First Middle Last Suffix Institutional Representative Email Institutional TitleInstitutional Mobile PhoneTo be used for on-site contact, if needed.How to get your free registration(s)?Once your membership level is confirmed, your logistics contact will receive the complimentary registration discount code(s) to distribute to the designated registrant(s) at your institution. Designated registrants will enter the discount code(s) when registering with the ASC on-line registration system. If any designated registrant has previously registered for the meeting, the fee will be reimbursed. Deadline: JANUARY 11, 2019 Institutional Logo and BlurbIf you cannot provide your logo, blurb or video now, you will have the option to provide it via the link to be included in your confirmation email. Deadline: JANUARY 11, 2019Please upload your institution's logo (.png, .jpg, or .tif file)Accepted file types: jpg, png.Institutional BlurbPlease submit a 50-75 word blurb about your institution which will be highlighted on the meeting app along with your logo. Deadline: JANUARY 11, 2019Institutional Video Guidelines (Platinum Members only)Deadline: JANUARY 11, 2019 1.Quality: Videos must be of good quality and submitted in final form 2.Acceptable formats (Windows PC compatible): MPEG, Quicktime, MP4, H.264, AVI • Framesize: No smaller than 640 x 480 • File size: Less than 1 gig 3. Runtime: 60 seconds maximum 4. Submission: Please submit your videos via Dropbox. Do not include any music, video clips or other materials/media copyrighted by any other entity other than your institution.PhoneThis field is for validation purposes and should be left unchanged.