Preceptor/Student

Sunday, 20 of May of 2012

Preceptor/Student

Payment Information for Preceptor/Student Registration

***FOR ALL PRECEPTORS/STUDENTS, ALL OF THE FIELDS BELOW ARE REQUIRED. PLEASE ENTER N/A IF ANY REQUIRED ANSWERS ARE NOT APPLICABLE. (For example, you would enter N/A for middle initial if you did not have a middle name).***

Payment Fee Type:
Registered and fee paid by March 5, 2012 ($260.00)

LATE REGISTRATION Registered and fees paid after March 5 2012 ($315.00)

Amount:

First Name:

Middle Initial:

Middle Name:

Last Name:

E-Mail:

Phone (###-###-####):

Institution Name:

Street:

City:

State:

Zip:

JUDGE/MODERATOR ASSIGNMENTS:
Preceptors are required to be a judge and/or moderator during at least one session
Please check one or more of the following categories that you would be interested in judging and/or moderating.
Primary Care/Ambulatory Care
Clinical Services Management
Internal Medicine
Infectious Disease
Pedicatrics/Neonatology
Hematology/Oncology
Critical Care
Cardiology
Community Practice
Pharmacy Practice
Transplant
Psych

Payment Options

Enter the security code as it is shown (required):

PAY BY PAPER CHECK :

Please make checks payable to: Midwest Pharmacy Residents Conference

Mail a copy of your registration form and payment to:

Dana J. Price
Office Coordinator, Pharmacy/Pathology Services
THE NEBRASKA MEDICAL CENTER
988138 Nebraska Medical Center
Omaha, NE 68198-8138

HOTEL ACCOMMODATIONS AT THE CONFERENCE:

You are responsible for your own hotel arrangements. To make hotel reservations please see the “Lodging and Travel” page on our website.

mprc

Preceptor/Student