Marketing and Referrals Workshop

*First Name

*Last Name

*Title

*Agency Name

*Address

Address 2

*City

*State

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware D.C. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

*Zip Code

*Phone

*Email Address

Optional 2nd Email Address This email will receive an initial confirmation notice letting you know the registration was recieved.

Early Registration Fees

Hospice Provider Member on or before 8/1/09 - $165 Individual Member on or before 8/1/09 - $175 Non-Member on or before 7/20/07 - $330

Standard Registration Fees

Hospice Provider Member 8/2 through 10/16/09 - $175 Individual Member 8/2 through 10/16/09 - $185 Non-Member 8/2 through 10/16/09 - $350

Late Registration Fees

Hospice Provider Member after 10/16/09 - $185 Individual Member after 10/16/09 - $195 Non-Member after 10/16/09 - $370

Payment Method

Visa Master Card Discovery Card Bill Me/Agency Purchase Order

If Paying by Credit Card - Name on Credit Card.

Billing Address:

Credit Card Number:

Expiration Date

3-Digit Security Code on Back of Credit Card

If paying by purchase order, please include your PO number in this field.

Comments

ADA Requirements

Cancellation Policy: Cancellations for this program must be received in writing at The Carolinas Center by 5:00 pm on Wednesday, October 16, 2009. Cancellations received by that date will receive a refund, less a $50 administrative fee. No refunds will be given for cancellations received after October 16; however, substitutions may be made.