Payment Information |
Registration fee includes all program materials and on-site meals including breakfast, breaks, and lunch.
Payment via Visa, Master Card, Discover Card, or American Express can be made upon completion of this online registration. Electronic checks are also accepted. No payments or registrations will be accepted by phone.
Questions about conference program should be directed to Beth Zielinski-Habershaw, PhD at bzielinski@uri.edu or 401.741.7451. Questions about payment and registration should be directed to Brenda Norris at 401.874-5552. |
Program Registration
|
Number Attending | |
@ $1000 |
Personal Information |
* indicates required field. |
Title (Mr., Ms., Dr.) |
|
First Name * |
|
Middle Name |
|
Last Name * |
|
Suffix (Jr.) |
|
Email Address * |
|
Preferred Name for Name Tag |
|
Credentials (PhD.,M.S.,Pharm.D.) |
|
Organization |
|
Affiliation |
|
URI Class Year |
|
Office Phone |
|
Mobile Phone * |
|
Dietary Restrictions (Vegan, Kosher, Allergies, etc) |
|
Other Requirements |
|
Billing Address |
Billing Address * |
|
Billing Address |
|
Billing City * |
|
Billing State/Province * |
|
|
Billing Postal Code * |
|
Billing Country * | |
Additional Attendees |
Click Add Another Attendee to enter the details to register an additional person(s) for this event. |
|
|
Institution Code |
|
Institutional Code | |
|
|
Total Discount Applied |
$ |
|
|
Total |
Total |
$ |
|
|
|
Please CHECK THE TOTAL AMOUNT and DO NOT click on REGISTER if this amount is incorrect or you are not prepared to pay.
|