Southeast Regional Integrative Medical Conference – Legends of Medicine Please enter a Username to create an account. If you already have an account please login before completing this form. Username * Check Availability Punctuation is not allowed in a Username with the exception of periods, hyphens and underscores. Conference Fee If you have a discount code, enter it here Apply Registration * Early Bird - $ 499.00 Student - $ 99.00 1-Day Practitioner Member - $ 239.00 1-Day Practitioner Non-Member - $ 317.00 1-Day Student - $ 89.00 Total Credit Card Card Type - select - Visa MasterCard Amex Discover Card Number * Security Code * Expiration Date * -month- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec -year- 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 Billing Name and Address Billing First Name * Billing Middle Name Billing Last Name * Street Address * City * Country * - select - United States State/Province * - select State/Province - Alabama Alaska American Samoa Arizona Arkansas Armed Forces Americas Armed Forces Europe Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas United States Minor Outlying Islands Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Postal Code * 2023 Conference Registration First Name * Last Name * Credentials * e.g. MD, RN, DC, FNP Continuing Education Category - select Continuing Education Category - APA PRA Category 1 Chiropractic CEU certificate License State * License Number * Email * Mobile Phone Referred By Street Address Address 1 City Country - select Country - United States State - select State/Province - Alabama Alaska American Samoa Arizona Arkansas Armed Forces Americas Armed Forces Europe Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas United States Minor Outlying Islands Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Postal Code Additional Options Attend Heroes & Villains Costume BallBe a Mentor -Welcome a New Practitioner to NCIMSNew to NCIMS/Functional Medicine Review
