ASC Institutional Confirmation Kit How to Get Your Free Registration(s)Step 1 of 8 - Start12%Demonstrate your support of the 2018 ASC to more than 1,500 surgeon attendees! Gain national visibility with leaders and members of two surgical associations dedicated to the advancement of surgical science – the Association for Academic Surgery (AAS) and the Society of University Surgeons (SUS). Institutional Member BenefitsReceive one or more complimentary registrations to the ASC MeetingReceive one or more complimentary registrations to the Grant Writing Workshop at the Platinum, Gold or Silver LevelBe recognized at the Opening Session by the presidents of the AAS and the SUSReceive a plaque commemorating your institution’s participationPlease select a level of membership to confirm your participation as an Institutional Member. Deadline: DECEMBER 5, 2017 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 Payment Options – I would like toPay NowPay later with check or a wire transfer . Please provide an invoice.This payment has already been fulfilled.Total $0.00 Credit CardAmerican ExpressDiscoverMasterCardVisa Card Number Expiration Date Month010203040506070809101112 Year20172018201920202021202220232024202520262027202820292030203120322033203420352036 Security Code Cardholder Name InstitutionDepartment Chair Name First Middle Last Department Chair PhoneDepartment Contact Email Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country 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 GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Pre-Meeting Logistics Contact Name First Middle Last Pre-Meeting Logistics Contact PhonePre-Meeting Logistics 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. DEADLINE: JANUARY 5, 2017 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. Institutional Representative Name First Middle Last Suffix Institutional Representative Email Institutional TitleMobile PhoneTo be used for on-site contact, if needed. Institutional Logo and Blurb If you cannot provide your logo, blurb or video now, you will have the option to provide it via the link to be included. Deadline: DECEMEBER 5, 2017 Please upload your institution's logo.Accepted file types: jpg, png.Please submit a 50-75 word blurb about your institution which will be highlighted on the meeting app along with your logo. Deadline: DECEMEBER 5, 2017 SUBMIT YOUR APPLICATION BY CLICKING ON THE SUBMIT BUTTON BELOWNameThis field is for validation purposes and should be left unchanged.