Instructions: Please complete entire application. You must indicate all of the events you plan to attend in order to reserve your space at each of the events. After you complete the form, please make your check payable for the total amount due and send to VSHP, P.O. Box 2567, Falls Church, VA 22031-2567.
| Name | |||
| Mailing Address | |||
| City/State/Zip | |||
| Home Phone Number | (____) ___-______ |
Email Address | |
| Practice Site | |||
| Address | |||
| City/State/Zip | |||
| Business Phone | (____) ___-______ | Fax Number | (____) ___-______ |
| Job Title | |||
| Specialty Area of Practice | |||
| Pharmacist Member |
Pharmacist Non-Member |
Resident Member |
Resident Non-Member |
Technician Member |
Technician Non-Member |
Student Member |
Student Non-Member |
Guest/Spouse | |
| Full Registration | $125 | $220 | $95 | $130 | $95 | $120 | $75 | $100 | $95 |
| Friday Only Registration | $95 | $190 | $75 | $110 | $75 | $100 | $75 | $100 | $95 |
| Saturday Only Registration | $95 | $190 | $75 | $110 | $75 | $100 | $75 | $100 | $95 |
A $25 late fee will be charged for all registrations received after September 26, 2008
| Dollar Amount |
Attending |
Event |
| $_____________ | Seminar Registration Fee | |
| $____Free*_____ | Yes / No |
I plan to attend the Breakfast Presentation on Friday, October 17 |
| $____Free*_____ | Yes / No |
I plan to attend the Awards Banquet on Friday, October 17 |
| $____Free*_____ | Yes / No |
I plan to attend the Breakfast Presentation on Saturday, October 18 |
| $____Free*_____ | Yes / No |
I plan to attend the ASHP Lunch Synposium Saturday, October 18 |
| $____Free*_____ | Yes / No |
I plan to attend the Residency Forum Friday, October 17 |
| $_____________ | Total Due, Made Payable to VSHP |
*Free to full meeting registrants and VSHP members
In order to reserve your space at each of the events, you must indicate all of the events you plan to attend by marking the space provided. If you did not indicate that you plan to attend the Banquet on your registration form, we will only be able to accommodate you on a space available basis on the weekend of the seminar.
We now offer 2 options for payment of your registration fee
Check here to pay by check - Please make your check payable to VSHP _______
or
Click here and pay using PayPal