NJSHP

ONLINE REGISTRATION CLOSED

DO NOT FAX YOUR REGISTRATION. AT THE DOOR REGISTRATIONS WILL BE ACCEPTED.

REGISTRATION FORM
Please forward all checks payable to NJSHP along with the completed registration form to:
New Jersey Society of Health-System Pharmacists
760 Alexander Road, P.O. Box 1, Princeton, NJ 08543-0001
Attn: Stella Williams 609-936-2205 Fax: 609- 936-2176

Informative Innovative Indispensable
April 8, 2011
Hilton East Brunswick, 3 Tower Center Blvd., East Brunswick, NJ, 08816

(PLEASE PRINT CLEARLY)

Name:

Address:

Institution/Company::

Home or Work Phone (include area code):

Email (write clearly):

Date:

Chapter:

Amount Enclosed: $

		(After March 18, add a $20 late fee)
		(Please check all that apply)

Full Registration, Dinner: Member		Full Registration, Dinner: Non-Member

	Pharmacist/Retired/New Practitioner/Supporting $115+$20=$135		Pharmacist/Retired/New Practitioner/Supporting $300+$20=$320

	Certified Technician $80+$20=$100		Certified Technician $250+$20=$270

	Technician $80+$20=$100		Technician $250+$20=$270

	Resident/Fellow $80+$20=$100		Resident/Fellow $250+$20=$270

	Student $60+$20=$80		Student $125+$20=$145

Full Registration, NO Dinner: Member		Full Registration, NO Dinner: Non-Member

	Pharmacist/Retired/New Practitioner/Supporting $85+$20=$105		Pharmacist/Retired/New Practitioner/Supporting $275+$20=$295

	Certified Technician $55+$20=$75		Certified Technician $225+$20=$245

	Technician $55+$20=$75		Technician $225+$20=$245

	Resident/Fellow $55+$20=$75		Resident/Fellow $225+$20=$245

	Student $35+$20=$55		Student $100+$20=$120

	DINNER ONLY ( $100+$20=$120pp) (Includes Cocktail Reception & Exhibition)


PLEASE MAKE CHECK PAYABLE TO:	NJSHP (TAX I.D. #22-2419542)

Credit Card Payment: Card Type (Circle One)

VISA

AMEX

Credit Card Number:

Exp Date (MM/YY):

_____/_____

CVV code (on back): ____

Date: ________

Name (as it appears on the card):

Signature:

Billing Address (only if different from mailing address):


	Street

City	State	Zip (MUST)

Refund Policy: Registrants will receive refunds minus a $20.00 administrative fee, provided that the cancellation request is received in writing by NJSHP at the headquarters by March 18, 2011. Payments to NJSHP are not deductible as charitable contributions for federal income tax purposes. However they may be deductible under other provisions of the Internal Revenue Code.

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