National Association of State EMS Officials by E3G1Xf


									                               National Association of State EMS Officials
                                                  Mid-Year Meeting
                                           March 5-7, 2013 ● Renaissance Plaza Hotel
                                                 General Registration Form

Program:                                  Who should attend: Members of NASEMSO and federal officials with a role in
Posted at                emergency medical services (EMS) are encouraged to attend. The NASEMSO Mid-Year
                                          Meeting purpose is to address EMS issues, particularly those with regulatory implications,
Registration Fee:                         such as EMS personnel and vehicle licensing, pre-hospital data (NEMSIS), two-way radio
$240 includes councils, committees,       communications, EMS for children, EMS medical direction, trauma and other regionalized
and all applicable NASEMSO                systems of care, and more.
program functions                         For more information: 703-538-1799                          
(Single Day Registration: $125)                                       Name:

Program Includes:                         Select your                 Nickname for Badge:
Handouts, breaks, and lunch.              registration:               Title:
                                             Payment enclosed
Meeting Location:                            Please invoice me        Organization:

Renaissance Hotel                                                     Address:
999 9th Street NW
                                          $      Amount
Washington, DC 20001                                                  City/St/Zip:
                                          enclosed (or to be
(across from Washington
                                          invoiced)                   Phone:                                     Fax:
Convention Center)
Hotel Accommodations                      If attending a single day
NASEMSO does not have a block             please indicate which
of rooms. NASEMSO attendees
will be able to select from nearby
                                          day you will be
                                                                      Payment            Check (payable to NASEMSO – U.S. funds only)
hotels at the EMS Today conference                                    Method:            Visa                 MasterCard
rate. To access the reduced hotel            Tuesday                                     American Express Purchase order
rate, reserve online by clicking hotel       Wednesday                Name on card:
registration and entering the dates of       Thursday
your reservation. Note: Shuttle                                       Card number:        .
service will be provided between the                                  Exp. Date:                           Signature:
Double Tree and the Renaissance by        IMPORTANT:
EMS Today.                                Please indicate which            Please check here to authorize if completing form electronically.
                                          Meeting(s) you will be      Security Code (Located on Front or Back of Card):
                                                                      Credit Card Billing Address:
                                          Councils (Tuesday &
                                            Data Managers
                                            Education Prof Stan.
                                            Trauma Managers

If you are attending as the official liaison of a NASEMSO             Cancellations received 14 days prior to the event will be granted a 50%
partner organization, please so indicate, providing your title        refund. No refund or credit can be given for requests received less than
with that organization:                                               14 calendar days prior to the event. since NASEMSO must incur expenses
                                                                      and assuming your participation. If you do not cancel your registration in
Title:_____________________________________________                   writing and do not attend, full fees are due; you may however, send a
                                                                      substitute in your place.
Organization:______________________________________                   Participation in NASEMSO events and all associated activities is at
                                                                      individual’s own risk.
                                                Fax, mail, or email this form to:
                                          NASEMSO ● 201 Park Washington Ct. ● Falls Church, VA 22046
                                         Fax: 703-241-5603 ● Phone: 703-538-1799 ●

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