Eastern Medicaid Pharmacy Administrators Association

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					                   Eastern Medicaid Pharmacy Administrators Association

CONNECTICUT-DELAWARE-MAINE-MARYLAND-MASSACHUSETTS-NEW HAMPSHIRE-NEW JERSEY-NEW YORK-PENNSYLVANIA-RHODE ISLAND-VERMONT-WASHINGTON D.C.-WEST VIRGINIA




                                         Non-State Representative Registration
                                            36th Annual EMPAA Conference
                                  Sunday, October 28 - Wednesday, October 31, 2012
                                        Hunt Valley Inn, Hunt Valley, Maryland
                       Participants are responsible for making their own hotel reservations 
        Contact the Hunt Valley Inn directly at 410-785-7000 (mention you’re attending EMPAA) or reserve online at
                https://reservations.ihotelier.com/crs/g_reservation.cfm?groupID=823848&hotelID=76975.
                                                         GENERAL INFORMATION
    NAME:
    COMPANY:
    BUSINESS ADDRESS:
    CITY:                                                                     STATE:                            ZIP:
    PHONE:                                                                    EMAIL:
                                                      CONFERENCE INFORMATION
    * Fees may be paid by: 1) online submission to jen.palow@empaa.org (security of online submissions cannot be guaranteed) or 2) mail
    by printing and then sending this form with payment information or check to Jennifer Palow, 151 Rideout St., Waterville, ME 04901.
    Questions may be directed to Jennifer Palow at 207-287-2705.
    ARRIVAL DATE:                                                             DEPARTURE DATE:
                   ATTENDEE                                     *FEE               # OF ATTENDEES                           TOTAL
    NON-STATE REPRESENTATIVE                                    $1,250                                                       $
    SPOUSE/GUEST                                                $ 750                                                        $
    SPOUSE/GUEST NAME:
              PLEASE CHECK THE FOLLOWING EVENTS THAT YOU AND/OR A GUEST WILL ATTEND
    SUNDAY, OCT. 28                                     RECEPTION AND DINNER                       # OF   ATTENDEES:
    MONDAY, OCT. 29                                     BREAKFAST                                  # OF   ATTENDEES:
    MONDAY, OCT. 29                                     LUNCH                                      # OF   ATTENDEES:
    MONDAY, OCT. 29                                     RECEPTION AND DINNER                       # OF   ATTENDEES:
    TUESDAY, OCT. 30                                    BREAKFAST                                  # OF   ATTENDEES:
    TUESDAY, OCT. 30                                    LUNCH                                      # OF   ATTENDEES:
    TUESDAY, OCT. 30                                    RECEPTION AND DINNER                       # OF   ATTENDEES:
    WEDNESDAY, OCT. 31                                  BREAKFAST                                  # OF   ATTENDEES:
    PLEASE LIST ANY DIETARY RESTRICTIONS:
    PAYING BY CREDIT CARD: In the non-shaded areas below, complete ALL of the required information.
    Credit Card Account #                                              Credit Card Exp. Date    Security Code   Amount Charged

    Name as it Appears on Credit Card

    IMPORTANT: Credit card’s exact billing address (must be street address)                     City            State        Zip Code

				
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posted:10/1/2012
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