Institutional Membership Form Please indicate your level of institutional sponsorship: Platinum Member Gold Member Silver Member Bronze Member Coffee and Conversations (Silver and Bronze Members Only) Sponsorship LevelPlatinum Member - Promote your institution through a 60 second video to be shown during selected breaks -Coffee and Conversations – Connect with leaders from leading institutions. Opportunity for trainees to meet with representatives from institutions to learn about their culture, programs, fellowships and more. - 4 free meeting registrations - Recognized as a Platinum Member during the Opening Session by the presidents of the AAS and SUS - Acknowledged as a Platinum Member on the ASC website, meeting app, in communications with registrants and throughout the course of the meeting Gold Member -Coffee and Conversations – Connect with leaders from leading institutions. Opportunity for trainees to meet with representatives from institutions to learn about their culture, programs, fellowships and more. - Receive 3 free meeting registrations - Acknowledged as a Gold Member on the ASC website, on the meeting app, in communications with registrants and throughout the course of the meeting Silver Member - Receive 2 free meeting registrations - Acknowledged as a Silver Member on the ASC website, on the meeting app, in communications with registrants and throughout the course of the meeting -Optional: Select 'Coffee and Conversations' for an additional $1,000 Bronze Member - Receive 1 free meeting registration - Acknowledged as a Bronze Member on the ASC website, on the meeting app, in communications with registrants and throughout the course of the meeting -Optional: Coffee and Conversations for an additional $1,000 Coffee and Conversations NEW THIS YEAR - Connect with leaders from leading institutions. Opportunity for trainees to meet with representatives from institutions to learn about their culture, programs, fellowships, and more. Free for Platinum and Gold members. $1,000 for Silver and Bronze members. Select this option if you would like to add it to your Silver or Bronze membership. Would you like to participate in Coffee and Conversations? Yes No Which day do you prefer to participate? Tuesday, Feb. 11th 6:30am-7:30am Thursday, Feb. 13th 6:30am-7:30am Institution InformationInstitution Name/TitleAs you want it to appear on meeting app and websiteAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Institution/Department Website Pre-Meeting Logistics ContactThe Logistics Contact will serve as the liaison between the institution and ASC staff. Responsibilities include: -Payment for institutional membership -Provide Institutional LOGO -Provide Institutional VIDEO (Platinum only) -Provide Institutional profile for meeting app -Distribute discount code among those selected from your institution to receive free registration(s) and ensure they are used. -Coffee and Conversations contact Pre-Meeting Logistics Contact Name First Last Pre-Meeting Logistics Contact PhonePre-Meeting Logistics Contact Email Department Chair Name First Last Department Chair PhoneDepartment Contact Email Institutional RepresentativeAs part of the Opening Ceremony, Institutional Members are recognized for their participation. Your chosen Institutional Representative (IR) will be called to the stage to accept a certificate of appreciation from the AAS and SUS presidents. There is no verbal (speech) component to receiving the certificate.Institutional Representative Name First Last Institutional Representative Email Institutional TitleInstitutional Mobile PhoneTo be used for on-site contact, if needed.Coffee and Conversations On-Site ContactThis is the individual from your institution who is responsible for being at the event on the assigned date. Coffee and Conversations On-Site Contact Name First Last Coffee and Conversations On-Site Contact Email Coffee and Conversations On-Site Contact 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 to distribute to the designated registrant(s) at your institution. Designated registrants will enter the discount code when registering with the ASC on-line registration system. If any designated registrant has previously registered for the meeting, the fee will be reimbursed. NOTE: Deadline to use free registration code is Monday, January 13, 2025 Institutional Logo and ProfileIf you cannot provide your logo, profile or video now, you will have the option to provide it via the link to be included in your confirmation email. Deadline: Friday, December 13, 2024Please upload your institution's logoAccepted file types: jpg, png, Max. file size: 64 MB.Institutional ProfilePlease submit a 50-75 word profile about your institution which will be highlighted on the meeting app along with your logo. Deadline: Friday, December 13, 2024Institutional Video Guidelines (Platinum Members only)Deadline: December 13, 2024 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.Total $0.00 Payment Options – I would like to*Payment deadline: Monday, January 13, 2025 Pay Now Pay later with check or a wire transfer Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20252026202720282029203020312032203320342035203620372038203920402041204220432044 Expiration Date Security Code Cardholder Name NameThis field is for validation purposes and should be left unchanged. Share this: Click to share on X (Opens in new window) X Click to share on Facebook (Opens in new window) Facebook