VSHP 2008 Spring Seminar Registration

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,PO Box 2567, Fairfax, 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

 

Seminar Registration: Please indicate what portion of the continuing education program you plan to attend by circling the applicable designation. Please remember space is limited, so . . . Register TODAY

 

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

$95

$190

$75

$110

$75

$100

$75

$100

$95

Saturday Only

$95

$190

$75

$110

$75

$100

$75

$100

$95

A $25 late fee will be charged for all registrants received after March 14th

Dollar Amount

Event

$_____________

Seminar Registration Fee

$T___Free*_____T

I plan to attend the Opening Night Banquet on Thursday March 27th

$T___Free*_____T

I plan to attend the breakfast on Friday March 28th

$T___Free*_____T

I plan to attend the breakfast on Saturday March 29th

$T___Free*_____T

I plan to attend the Luncheon Forum on Saturday March 29th

$_____________

Total Due, Made Payable to VSHP

*Free to full meeting registrants and VSHP members
In order to reserve your space, you must indicate all the events you plan to attend by marking the space provided. If you do not indicate that you plan to attend the Banquet on your registration form, we will only be able to accommodate you on a space-availability 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

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