NLNAC 2010 Self-Study Forums
REGISTRATION FORM
*required fields

* LOCATION

       Chicago, Illinois - March 25-26, 2010 (Registrations Closed - Filled to Capacity)
         Click here for Chicago Forum Agenda
  
       Atlanta, Georgia - April 8-9, 2010 (Registrations Closed - Filled to Capacity)
       Host Hotel: Westin Buckhead - Atlanta, Georgia
         Click here for Atlanta Forum Agenda

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

GOVERNING ORGANIZATION/WORK AGENCY INFORMATION
* Program Type(s): Clinical Doctorate 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 404.975.5020.

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.
       Reference No.

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

  
Comments:

REGISTRATION FEES
Registration on or before February 26, 2010 (Chicago) and March 12, 2010 (Atlanta)
$ 345.00 per participant
   295.00 per participant if 3 or more registrations from the same governing organization or agency.
Registration after February 26, 2010 (Chicago) and March 12, 2010 (Atlanta)
$ 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:

Brad Davis, Administrative Assistant for Systems Support
Phone: (404) 975-5000
Fax:  (404) 975-5020
bdavis@nlnac.org