| * AVAILABLE FORUM DATES (Please select one) |
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Atlanta, Georgia - March 28 - 29, 2011
Host Hotel: Westin Buckhead Atlanta Hotel, Atlanta, Georgia
SPECIAL SESSION: Focus on Standard 6
Will attend the Special Session: Yes No
Atlanta, Georgia - March 31 - April 1, 2011
Host Hotel: Westin Buckhead Atlanta Hotel, Atlanta, Georgia
SPECIAL SESSION: New Programs, New Faculty, and New Administrators
Will attend the Special Session: Yes No
Anaheim, California - April 27 - 28, 2011
Host Hotel: Hilton Anaheim Hotel, Anaheim, California
SPECIAL SESSION: Focus on Standard 6
Will attend the Special Session: Yes No
Click here for Self-Study Forum Agenda Note: Please do not make travel arrangements prior to receiving confirmation of forum registration.
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| 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 |
| REGISTRATION FEES
Registrations processed on or before Monday, February 28, 2011 (Atlanta) and Sunday, March 27, 2011 (Anaheim)
$ 395.00 per participant
345.00 per participant if 3 or more registrations from the same governing organization or agency.
Registrations processed after Monday, February 28, 2011 (Atlanta) and Sunday, March 27, 2011 (Anaheim)
$ 445.00 per participant
395.00 per participant if 3 or more registrations from the same governing organization or agency.
Please select your preferred method of payment: |
| Check or Money Order
Payment due upon receipt of NLNAC invoice.
Credit Card (Please complete the Billing Address Information below.)
An NLNAC Accounting Associate will be contacting you
by phone to process credit card information.
Credit Card Billing Address:
Address 1:
Address 2:
City:
State:
Zip:
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. |
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