Utah Academy of Physician Assistants

CME Mesquite Registration 2008

Date:

Please complete the registration form below, and then press 'Print'. Submit your registration form, along with your check to the address at the bottom.

Registrations postmarked by April 1st will be accepted. Any received thereafter need to register at the conference.

For questions, Contact Vickie Hamm at  801-231-4373  or 801-266-7656

Note that items marked with an "*" are required fields.


PERSONAL INFORMATION:
*Name
(First and Last):
*Address Line 1:
Address Line 2:
*City:
*State:
*Zip Code
*Home Phone:
Work Phone:
Cell Phone:
Fax:
*Email Address:
Title:  PA       MD       NP       Student     

TUITION:
*Please select one from the choices below:
Received by
  4/01/08
At the Door
UAPA Member $375.00 $425.00
Non-Member $450.00 $500.00
N.P. Member $410.00 $460.00
Student $50.00 $50.00
Single Day - Member $275.00 $300.00
Single Day Non-Member $300.00 $325.00
Single Day - Student $25.00 $25.00
 
Tuition Selected $
EXTRAS (NON-TUITION):
Event Nbr. Attending Cost per Attendee Extended Cost
Dinner - Adult Guest* @ $25.00
Dinner - Child Guest (under 11) @ $10.00
Golf - 18 holes @ $60.00
Practice Profitability Workshop @ $95.00
*Dinner (Friday night) - One dinner is included with each registration.

Total Enclosed: $


  
PAYMENT INSTRUCTIONS:
1) Complete all sections of the online form.
2) Print the completed form by using the 'print' button
3) Mail in the completed form along with your payment to:

     Utah Academy of Physician Assistants
     c/o Vickie Hamm
     230 East. Crawford St.
     Murray, UT 84107-4919

Make checks payable to Utah Academy of Physician Assistants

Payment is due with registration form.



(Utah Tax ID#: 87-0356036)


UAPA

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