NLNAC Fall 2012 Self-Study Forum
REGISTRATION FORM
*required fields

       Orlando, Florida - October 18-19, 2012
       Host Hotel: Walt Disney World Swan and Dolphin Resort

         SPECIAL SESSIONS:
         Thursday, October 18th - 9:30 AM- 11:00 AM
         The Novice Accreditee: A Session for New Programs, Faculty, and Administrators
         *Indicate if you plan to attend this Special Session:Yes  No
 
         Thursday, October 18th - 6:30 PM- 8:00 PM
         A Focus on Standard 6 Outcomes
         *Indicate if you plan to attend this Special Session:Yes  No

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

REGISTRATION FEES
Early Registrations processed on or before Friday, August 31, 2012
$ 395.00 per participant
   345.00 per participant if 3 or more registrations from the same governing organization or agency.
Registrations processed after Friday, August 31, 2012
$ 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.

  
Comments:
IMPORTANT INFORMATION:
Payment must be received to confirm registration. Cancellations will be charged $150.00. Fees are not refundable after August 31, 2012. 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:

Carla Haynes, Administrative Assistant for Systems Support
Phone: (404) 975-5011
Fax:  (404) 975-5020
chaynes@nlnac.org