Vet of the Year - New York State Wildlife Rehabilitation Council

Advance Registration FormNYSWRC’s 1 st Annual Veterinarian’sWildlife SeminarOffered in conjunction with the 33rd Annual ConferenceApproved as a New York Statesponsor of continuing education forveterinarians and veterinary techniciansI plan to participate in the Sunday, Oct. 27, 2013 seminar at the Byblos Resort & Spa on Grand Island, NY.Name:___________________________________________________________________________________Address:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Phone #:______________________________ Email address: ______________________________________(for NYSWRC response only-not to be shared with anyone)_____Yes, issue the NYS ED continuing education credits. My License #______________________________Advance Registration* includes box lunch _____vegetarian or _____ non-vegetarianPayment: $75. if paid by check—make checks payable to NYSWRC 2013Credit Card cost: $80. (includes $5. processing fee)______Optional: $25. to become a member of NYSWRCTotal $:_________Please give us the exact name on the account:If paying by credit card: ______Visa, or _____Master CardPrint name clearly_________________________________________________________________________________Signature_________________________________________________the account number: ____________________________________ Authorization # (3 digit, on back) _______________the expiration date: ____________________________, and/or, yes, you may use a Government Purchase Order #*Note: Cost is $100. if registering at the door.A confirmation and directions to the hotel will be sent upon receiptof this form.Return this entire page, completed with credit information,check or money order (in US dollars).Make checks out to: NYSWRC 2013 Canadian checks must be drawn on US banks.Mail to: Amy Freiman, PO Box 62, Newcomb, NY 12852(phone: 518-582-3655)After Sept. 1, mail to:6655 N Canyon Crest Dr., Unit 9151, Tucson, AZ 85750 (phone: 520-529-1151)