Registration Form Nwus 2008 Conference

NWUS SOCIETY 55th ANNUAL MEETING REGISTRATION December 5-6, 2008 Portland Marriott Downtown Waterfront, Portland, OR NWUS Contact Information:

www.nwus.org

NAME: ____ _________________________________

fax

(866) 800-3118 toll free

(360) 668-4053

GUEST NAME: ___________________________

ADDRESS: ___________________________________________________________________________ CITY: ______ _______________ TELEPHONE NUMBER:

STATE: _____ __________ ZIP: ____________________________

__________________________

FAX:

______________________

EMAIL_(Required)________________________________ CME CERTIFICATE (credit) is CME

Yes

□

No

□

optional and will be provided at an additional charge of $50.

CATEGORIES OF REGISTRATION After 17th 1

2

3 4 5 6 7

Before Nov. 17th

NWUS MEMBER: Whose Membership Dues are Paid Current □ Registration Fee - Meeting Only………….. ...………………………………………………………………$ 75 □ Registration Fee - Meeting and all events…….……………..………………………………….……………$ 75 □ Yes, I plan to attend the NWUS Membership Luncheon Meeting Saturday December 6th………………….

Nov. $100 $190

SENIOR MEMBER: □ Registration Fee-Meeting Only…………………………………………………………………………….....$ 75 $100 □ Registration Fee – Meeting and all events…………………………………………………….……………...$ 200 $225 □ Yes, I plan to attend the NWUS Membership Luncheon Meeting Saturday December 6th…………………. PROPOSED NEW MEMBER: □ Registration Fee- Meeting Only……………………………………………………………………………..$ 75 $100 □ Registration Fee– Meeting and all events……………………………………………………………….........$215 $240 NON-MEMBER PHYSICIAN: □ Registration Fee -Meeting Only………………………………………………..………………………….....$275 $300 □ Registration Fee –Meeting and all events………………………………………………………….…….......$365 $390 RESIDENT/FELLOW/STUDENT: □ Registration Fee - Meeting Only…………………………………………………………………………....$ 75 $100 □ Yes, I will attend the Resident’ Luncheon on Saturday, December 6th ALLIED HEALTH PROFESSIONAL □ Registration Fee – Meeting Only…………………………………………………………………………......$ 75 $100 □ Registration Fee – Meeting and all events……………………………………………………………….......$215 $240 COMPANY REPRESENTATIVE (Registration Fee – Meeting Only) ……………………………………….No Charge $ 25 □ Friday Night OMSI Reception……………………………………………………………………..$50 each x ____ _ = ___________

□ Saturday Night Banquet……………………………………………………………………………$90 each x ____ _ = ___________ 8 SPOUSE/GUEST MEAL TICKETS……….………… …………………………………………………Indicate # Requested and Amount

□ Friday Reception…… .....................................................................................................……….…FREE x _____ = □ Saturday Night Banquet……………………………………………………………………………$90 each x ____ _=

___________ ___________

Total Registration Fee: . .PAY . . . .IN . . .U.S. . . . . FUNDS . . . . . . . .–. CANCELLATION . . . . . . . . . . ………………..……………………… PLEASE FEE $25 ….._________ Registration and Payment OPTIONS 1) Return This Form with Your Check To: NWUS, 914 164th St. SE, Suite B-12 #145, Mill Creek, WA 98012

2) On-line registration www.nwus.org 3) Fax your completed form to 360-668-4053 with your credit card information Cardholder Account Number_______________________________ Expiration Date

PLEASE PAY IN U.S.FUNDS – CANCELLATION FEE IS $25.00 U.S.

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