Please enter the following information:
First Name:
Last Name:
Professional Designation:
Organization/Company:
Address Line 1:
Address Line 2:
City:
State (abbrev):
Zip Code:
Phone:
E-mail Address:
Cost:	Member full  $150.00 Member one day Thursday  $100.00 Member one day Friday  $100.00 non-member full (includes 2011 membership)  $275.00 non-member one day Thursday  $190.00 non-member one day Friday  $190.00 technician/resident member full  $45.00 technician/resident one day Thursday  $25.00 technician/resident one day Friday  $25.00 technician/resident nonmember full  $110.00 technician/resident non-member one day Thursday  $70.00 technician/resident non-member Friday  $70.00 Student Thursday  $15.00 Student Friday  $15.00 Student Full  $30.00
Attending Thursday Attendees Luncheon:	Yes   No
Attending Thursday Reception:	Yes   No
Attending Friday Attendees Luncheon:	Yes   No
Membership Join/Renewal:	Pharmacist  $125.00 Technician  $35.00 Resident  $10.00 Student  $10.00
Special Dietary Needs:
Payment Method	Credit Card