Symposium Registration - Step 1

Nurse / Allied Medical Personnel Registration

Degree(s): MD PharmD PhD RN - Other

Last Name*

First Name*

M.I.

Address*

City*

State**

Zip* (0 if none)

Country*

Affiliation

Office Phone*:

Home Phone:

Fax Phone:

(Please include country and city codes: xxx-xxx-xxxx)

Email*

(For confirmation of registration and payment - name@domain.com)

Specialty or Area of Practice:

 

*Fields with *asterisk are required.
**Fields with **asterisk are required in the United States.

 

REGISTRATION FEES

$50

1. Early-Bird On or before May 1, 2019

$75

2. Pre-Registration May 2, 2019 - May 31, 2019

$75

3. On-site Registration June 1, 2019

Only Visa, Mastercard, Amex and Discover accepted.
Mail in Option also available.

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