Annual Patient Conference Registration - Virtual Contact InformationName* First Last Email Address* Ticket InformationAnnual Patient Conference - Virtual*Patient/Spouse/Care PartnerRegistrationAttendee InformationAttendee 1Gender:* Female Male Prefer not to disclose Name* First Last Email Address* Describe your connection to Myositis*Please Choose OnePatientCare PartnerSpouseOtherSpecify your connection to Myositis* Form of MyositisPlease Choose OneDMIBMPMNMJMAS SyndromeOtherAre you a Veteran*Please Choose OneYesNoCheck this box if you grant TMA permission to include your name and contact information in conference materials which will be available to attendees.* Yes No Home PhoneMobile PhoneAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and 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Islands Country Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Expiration Date Security Code Cardholder Name Total $0.00 Ticket PricePhoneThis field is for validation purposes and should be left unchanged. 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