NLNAC 2009 Self-Study Forums
REGISTRATION FORM
*required fields

* LOCATION

Dallas, Texas - March 9-10, 2009
       Host Hotel: DoubleTree Hotel Dallas - Near the Galleria, Dallas, Texas
New Orleans , Louisiana - April 9-10, 2009
       Host Hotel: Hilton New Orleans Riverside, New Orleans, Louisiana

Note: Please do not make travel arrangements prior to receiving confirmation of forum registration. 

GOVERNING ORGANIZATION/WORK AGENCY INFORMATION
* Program Type(s): Master's Baccalaureate Associate Diploma Practical Other 
* Governing Organization
or Work Agency:
Nursing Education Unit
or Department:
* Address:
* City:
* State:
* Zip:
* Phone:
Extension:
Fax:

PARTICIPANTS
* Indicate Number of Participants:
* All fields are required for each participant.
If registering more than 3 individuals, please print form and fax to 212.812.0390.

Participant 1
  First Name:
  Last Name:
 Credentials:
  Job Title:
  Email:

Participant 2
  First Name:
  Last Name:
  Credentials:
  Job Title:
Email:

Participant 3
First Name:
  Last Name:
 Credentials:
  Job Title:
  Email:

PAYMENT INFORMATION

Please select your preferred method of payment:

Check or Money Order
Payment due upon receipt of NLNAC invoice.      

Credit Card
An NLNAC Accounting Associate will be contacting you by phone to process credit card information.

 NLNAC Voucher Certificate
Please provide Voucher No. and Reference No.

Purchase Order
If your institution requires a Purchase Order (P.O.)
Please enter P.O. No.

  
Comments:

REGISTRATION FEES
Registration before end of day - February 20, 2009 (Dallas Self-Study Forum) and March 9, 2009 (New Orleans Self-Study Forum)
$ 345.00 per participant
   295.00 per participant if 3 or more registrations from the same governing organization or agency.
Registration after February 20, 2009 (Dallas Self-Study Forum) and March 9, 2009 (New Orleans Self-Study Forum)
$ 395.00 per participant
   345.00 per participant if 3 or more registrations from the same governing organization or agency.

IMPORTANT INFORMATION:
Payment must be received to confirm registration. Cancellations will be charged $150.00. Fees are not refundable two weeks prior to Forum date . Click here for more detailed information on fees and cancellation policies. Travel or hotel arrangements should be made after you have received confirmation of your registration from the NLNAC office.

If you have any questions, please contact:

Anthony Bugay, Board Liaison & Manager of Special Projects
Phone: (800) 669-1656 ext. 261
Fax:  (212) 812-0390
abugay@nlnac.org