NWUS SOCIETY 55th ANNUAL MEETING REGISTRATION

December 5-6, 2008 Portland Marriott Downtown Waterfront, Portland,

OR
NWUS Contact Information: www.nwus.org (866) 800-3118 toll free (360) 668-4053
fax

NAME: ____ _________________________________ GUEST NAME: ___________________________

ADDRESS: ___________________________________________________________________________
CITY: ______ _______________ STATE: _____ __________ ZIP: ____________________________
TELEPHONE NUMBER: __________________________ FAX: ______________________
EMAIL_(Required)________________________________

CME CERTIFICATE (credit) is optional and will be provided at an additional charge of $50.
CME Yes □ No □
CATEGORIES OF REGISTRATION Before
After
Nov. 17th Nov.
17th
1 NWUS MEMBER: Whose Membership Dues are Paid Current
□ Registration Fee - Meeting Only………….. ...………………………………………………………………$ 75 $100
□ Registration Fee - Meeting and all events…….……………..………………………………….……………$ 75 $190
□ Yes, I plan to attend the NWUS Membership Luncheon Meeting Saturday December 6th………………….
2 SENIOR MEMBER:
□ Registration Fee-Meeting Only…………………………………………………………………………….....$ 75 $100
□ Registration Fee – Meeting and all events…………………………………………………….……………...$ 200 $225
□ Yes, I plan to attend the NWUS Membership Luncheon Meeting Saturday December 6th………………….
3 PROPOSED NEW MEMBER:
□ Registration Fee- Meeting Only……………………………………………………………………………..$ 75 $100
□ Registration Fee– Meeting and all events……………………………………………………………….........$215 $240
4 NON-MEMBER PHYSICIAN:
□ Registration Fee -Meeting Only………………………………………………..………………………….....$275 $300
□ Registration Fee –Meeting and all events………………………………………………………….…….......$365 $390
5 RESIDENT/FELLOW/STUDENT:
□ Registration Fee - Meeting Only…………………………………………………………………………....$ 75 $100
□ Yes, I will attend the Resident’ Luncheon on Saturday, December 6th
6 ALLIED HEALTH PROFESSIONAL
□ Registration Fee – Meeting Only…………………………………………………………………………......$ 75 $100
□ Registration Fee – Meeting and all events……………………………………………………………….......$215 $240
7 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 ____ _= ___________
PLEASE
Total Registration Fee: . .PAY
. . . .IN
. . .U.S.
. . . . FUNDS
. . . . . . . .–. CANCELLATION 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.