Untitled Document

Wayne State University
Eugene Applebaum College of Pharmacy and Health Sciences
Department of Nurse Anesthesia

26th Annual Anesthesia Seminar
Conference Registration Form

Click here for Vendor Registration

Registration Information

First Name:

Last Name:

State/Province:

Address:

Zip/Postal Code:

City:

Country:

Cell/Home Phone:

Business Phone:

AANA ID#:

Email:

Employer / School:

City:

State/Province:

Zip/Postal Code:

Registration Includes:

Registration Fees

* Continental Breakfast
* Lunch
* Afternoon Refreshments
* Course Outlines
* Parking

	CRNA --- $165.00
	Anesthesia student --- $50.00
	MD / DO --- $175.00
	RN / Other Clinician --- $100.00
	Check here for Vegetarian lunch

	Onsite Registration --- +20.00
	I will pay by mail

This form is for REGISTRATION ONLY. Submitting this registration form will inform the Nurse Anesthesia Program that you wish to attend the 2008 26th Annual Anesthesia Seminar. Payment reserves you a space.

Make checks payable to:
Detroit Receiving Anesthesia/Research & Education Fund

Mail Payment to:
Detroit Receiving Hospital & University Health Center
Anesthesia Department, Room 2V-4
4201 St. Antoine
Detroit, MI 48201

NO REFUNDS AFTER MARCH 22, 2008