OHSIPP/KYSIPP State Society Meeting August Registration Form 2019

REGISTRATION FORM

VENUE
Westin Cincinnati
21 E 5th St, Cincinnati, OH 45202 | (513) 621-7700 | Hotel Reservation

Personal Information:

First Name:*

Middle Initial:

Last Name:*

Organization:

Address:*

City:*

State:*

Zip:*

Phone:*

Cell:

Fax:

E-mail:*

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Payment Information

Physician Member$450.00

Physician Non-member$850.00

NP/PA$175.00

Fellows$150.00

Staff$100.00

Day Pass$250.00

Baseball Game Ticket Reds vs. Cubs *in addition to registration fees$83.00

Industry Partner (Non-Exhibitor) Individual$850.00

Total $0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

CANCELLATION POLICY:

OHSIPP/KYSIPP reserves the right to cancel this course upon reasonable notice and will assume no financial obligation to registrants for cancellation for reasons beyond its control. Registration fees will be refunded, however, costs incurred by the registrants, such as airline or hotel fees or penalties, are the responsibility of the registrants. OHSIPP/KYSIPP requires a 30-day notice of cancellation. Cancellations must be submitted in writing by July 9, 2019. Cancellations after July 9, 2019 but prior to July 25, 2019 will forfeit 50% of their registration fee. No refunds can be made after July 25, 2019.

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