2012 Conference Registration

MDS CONFERENCE REGISTRATION APPLICATION FORM

Sept 30 - Oct 2, 2012


First Name:
Last Name:
Title:
Company:
Address:
Suite#:
City:
State:
Zip:
Telephone:		(xxx)xxx-xxxx
Fax:		(xxx)xxx-xxxx
Email:		Required to recieve confirmation

Hotel rooms have been reserved for September 30 and October 1 at the Encore Las Vegas for the MDS reduced group rate of $199 per night plus tax. Call 866.770.7555 to reserve your room now. Pre-conference workshop on Sunday September 30, 2012
Healthcare Provider Organizations
	Early Registration - $695 (until July 30, 2012)
	Regular Registration - $795 (after July 30, 2012)
	Additional Registrants: $695 each

Non-Healthcare Providers
	Early Registration - $1095 (until July 30, 2012)
	Regular Registration - $1195 (after July 30, 2012)
	Additional Registrants: $1095 each

	Pre-conference Workshop Registration Sunday September 30, 2012, $295

	I will be paying by Check
	I will be paying by Credit Card

Credit Card Information
First Name:		As found on credit card
Last Name:		As found on credit card
Billing Address:
City:
State:
Zip:

Credit Card Number:
Expiration Date:		mm/yyyy
CCV:
Required field

Cancellation Policy A written notification is required for a refund (minus $150 for administrative fees) no later than August 30, 2012. After that date all fees are forfeited, however, you are encouraged to send a substitute if you cannot attend.

LOS ANGELES OFFICE: 24584 Hawthorne Blvd. | Torrance, CA 90505 | Tel: 424.237.2525
ORANGE COUNTY OFFICE: 535 Anton Blvd., Suite 880 | Costa Mesa, CA 92626 | Tel: 714.754.5424

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2012 Conference Registration

MDS CONFERENCE REGISTRATION APPLICATION FORM

Sept 30 - Oct 2, 2012

Cancellation Policy