Personal Information
*indicates
required field
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*First
Name:
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(as it
will appear on your name badge) |
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*Last
Name: |
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*Title: |
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*Organization: |
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*Address |
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*City: |
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*State: |
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*Country: |
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*Postal
Code:
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*Telephone:
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Cell
Phone: |
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*Email:
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Administrator's Name: |
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Administrator's Email:
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Invited by: |
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Accommodations
You are
responsible for payment for your accommodations.
Room Rate: $329.00 plus tax.
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Requested Arrival
Date: |
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Requested Departure
Date: |
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Requested Room
Type: |
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Smoking Preference: |
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Accommodation
Requests:
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(Other dates, Accessibility) |
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Credit
Card Required for Room Guarantee
Reservations will not be made at the W Hotel Washington
D.C. If these
fields are not complete. This card will not be charged
unless you "no show" for your room!
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*Credit
Card Type: |
(No Room" Option in drop down) |
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*Credit
Card Number:
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Expiration:
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(January
2011=0111)
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Other
Information |
Attending
Pre-Conference Workshop:
Global Compliance Training? |
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Attending
Wednesday Dinner? |
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Special Considerations:
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(Access,
Diet) |
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MCLE Units: |
(indicate State) |
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Early Bird
Registration Fee is $750.00 |
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