Class A Registration Form

Class A Registration Form
Please fill out this form completely so that we can update our records. You have the option to pay now with a credit card or you can send us a check. Please remember, if you choose to send in a check, your registration process will not be complete until we receive your check.

Membership Deadline: March 12, 2010
Membership Fee: $10
Meeting Registration Deadline: March 12, 2010
Meeting/Membership Fee: $95
(There will be a $25 late registration fee after this date.)

Demographics * First Name
* Last Name
Middle Initial
* Email Address

* Street Address

* City
* State
* Zip Code

* Phone Number

Employment Information *Year that you started in perfusion

2010WPS Spring Meeting * Would you like to register for the 2010 WPS Spring Meeting held March 26-28? Yes No
* Will You Be Attending the Friday Evening Program\Dinner? Yes No
* Will You Be bringing a guest (additional $30)? Yes No

Please Share any Questions or Comments with us:

* indicates Required Field.

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Demographics	* First Name * Last Name Middle Initial * Email Address * Street Address * City * State * Zip Code * Phone Number
*Employment Information*	*Year that you started in perfusion
*2010WPS Spring Meeting*	* Would you like to register for the 2010 WPS Spring Meeting held March 26-28? Yes No * Will You Be Attending the Friday Evening Program\Dinner? Yes No * Will You Be bringing a guest (additional $30)? Yes No
Please Share any Questions or Comments with us:
* indicates Required Field.