Annual Conference

Full Name _____________________________________________
First Name for Badge _____________________________________
Address _______________________________________________
City, State, Zip _ _________________________________________
Daytime Phone __________________________________________
Employer ______________________________________________
Position _______________________________________________
E-mail** _______________________________________________
**Required for registration confirmation
My mailing and e-mail addresses and position can be listed on the
conference participant list.
❏ Yes ❏ No
❏ Yes, I am willing to serve as a session moderator.
Please contact me if my services are needed.
If necessary, a copy of a purchase order
can accompany the registration form.
SCHEDULE SELECTION
Please indicate which Concurrent Sessions you are planning to attend
by checking one checkbox for each session series. You may change
your selection at any time without notifying the conference office:
Thursday, March 10:
Sessions A: ❏ 1 ❏ 2 ❏ 3 ❏ 4 ❏ 5
Sessions B: ❏ 1 ❏ 2 ❏ 3 ❏ 4 ❏ 5
Sessions C: ❏ 1 ❏ 2 ❏ 3 ❏ 4 ❏ 5
Friday, March 11:
Sessions D: ❏ 1 ❏ 2 ❏ 3 ❏ 4 ❏ 5
Sessions E: ❏ 1 ❏ 2 ❏ 3 ❏ 4 ❏ 5
Saturday, March 12:
Sessions F: ❏ 1 ❏ 2 ❏ 3 ❏ 4 ❏ 5
Refund/Cancellation Policy: Requests must be submitted via email to
info@nacns.org A $75 administrative fee will be deducted from the
refund. NACNS reserves the right to cancel this program and return all
fees in the event of insufficient enrollment. In the case of cancellation,
NACNS cannot be responsible for other registrant expenses, including
but not limited to, reimbursement of airline or other transportation
fares, hotel or rental charges, deposits, or penalties. NO REFUND RE-
QUESTS will be accepted after February 28, 2011.
Mail to:
NACNS
100 North 20th Street, Suite 400
Philadelphia, PA 19103
Fax to: 215-564-2175
Email to: info@nacns.org
ONLINE REGISTRATION AVAILABLE
AT WWW.NACNS.ORG
NACNS 2011 REGISTRATION FORM
REGISTRATION FEES
FULL CONFERENCE (THURS – SAT)
NACNS MEMBER:
❏ Early-Bird (received by 2/4/11) $425.00
❏ Advance (received by 2/28/11) $450.00
❏ Onsite $500.00
NACNS STUDENT MEMBER:
❏ Early-Bird (received by 2/4/11) $280.00
❏ Advance (received by 2/28/11) $305.00
❏ Onsite $355.00
NON-MEMBER:
❏ Early-Bird (received by 2/4/11) $575.00
❏ Advance (received by 2/28/11) $600.00
❏ Onsite $650.00
JOIN NACNS & REGISTER:
Full Member-
❏ Early-Bird (received by 2/4/11) $550.00
❏ Advance (received by 2/28/11) $575.00
❏ Onsite $625.00
Student Member-
❏ Early-Bird (received by 2/4/11) $360.00
❏ Advance (received by 2/28/11) $385.00
❏ Onsite $435.00
SINGLE DAY
NACNS MEMBER:
❏ Early-Bird (received by 2/4/11) $175.00
❏ Advance (received by 2/28/11) $200.00
❏ Onsite $250.00
STUDENT
❏ Early-Bird (received by 2/4/11) $120.00
❏ Advance (received by 2/28/11) $145.00
❏ Onsite $195.00
NON-MEMBER:
❏ Early-Bird (received by 2/4/11) $250.00
❏ Advance (received by 2/28/11) $275.00
❏ Onsite $325.00
PLEASE INDICATE WHICH SINGLE DAY:
❏ Thursday ❏ Friday ❏ Saturday
PRE-CONFERENCE SESSIONS:
❏ Single Session: $75.00
❏ Both Sessions: $130.00
Indicate Your Attendance:
❏ JBI Pre-Con ❏ Publication Pre-Con
POST-CONFERENCE SESSION:
❏ Pharmacology: $75.00
GRAND TOTAL:
$__________
Please indicate method of payment:
❏ Check (payable to NACNS)
❏ Credit Card (Visa, Mastercard, AmEx)
NACNS TAX-ID: 33-0671730
Card No._____________________________ Exp._ ______________
Card Holder Name________________________________________
PLEASE CONTACT NACNS AT 215-320-3881 IF SPECIAL
DIETARY OR MOBILITY ACCOMMODATIONS ARE REQUIRED