State Conference 2019 Registration Form
Use this form to confirm your payment and registration for the IdSMA 2019 State Conference. You can not submit this form without paying through PayPal first. If you do not have your receipt & transaction ID numbers from PayPal, please return to the website, select your registration options, and pay. Once you have paid through PayPal, you will get a confirmation page including receipt & transaction ID numbers. These may be on an email as well.
Email address *
Name (please include both first & last): *
Your answer
Address: *
including city, state and zip
Your answer
Preferred Phone Number (no dashes, please): *
Your answer
PayPal Receipt & Transaction Numbers *
You can not submit this form without paying through PayPal first. Please return to the website, select your registration option, and pay. Once you have paid through PayPal, you will get a confirmation page including receipt & transaction ID numbers. These may be on an email as well. Enter these numbers here please.
Your answer
Email address used in PayPal checkout *
Your answer
Registration Option: *
How long have you been a Medical Assistant (CMA, RMA, or MA) *
Students please write: Student at (insert school name)
Your answer
Local Chapter Affiliation: *
AAMA Membership Number: *
**This is NOT your certification number, this is the number on your AAMA Membership card.** If non-member please enter "Non-Member".
Your answer
Membership Expiration Date (from your annual membership card). Non-members skip this step.
This will not be a year greater than 2019.
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Have you ever been a State Officer or Delegate? *
Are You Interested in Running for a Delegate Position? *
If you purchased a 2019 Conference T-Shirt, please fill out the information below. If not, please just skip these questions. *Be aware that the shirts will shrink some. It is recommended that you order a size up.
If you purchased additional conference shirts, please let us know at the bottom of the form.
Please indicate the cut of your free t-shirt:
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Please indicate the color of your free t-shirt:
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Please indicate the size of your free t-shirt:
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Did you purchase additional conference t-shirts? *
If yes, please include the number in the additional information block below.
Any additional information you wish to include with your registration? (This step is NOT required)
Your answer
A copy of your responses will be emailed to the address you provided.
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