Resident/Fellow

Payment Information for Resident/Fellow Registration

** WE CANNOT ACCEPT ANY REGISTRATIONS AFTER MARCH 4, 2010 DUE TO CE SUBMISSION DEADLINES **

**FEES BELOW COVER CONFERENCE REGISTRATION ONLY AND DO NOT INCLUDE HOTEL CHARGES. ALL CONFERENCE ATTENDEES MUST PAY CONFERENCE REGISTRATION FEES - HOTEL EXPENSES ARE SEPARATE (PLEASE REFER BELOW AND TO "LODGING & TRAVEL" SECTION OF THIS SITE FOR ADDITIONAL INFORMATION)**

***FOR PRESENTING RESIDENT/FELLOWS ACCOMPANIED OR UNACCOMPANIED BY A PRECEPTOR. ALL OF THE BELOW FIELDS 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:
Residents/Fellows Accompanied by a Preceptor must register and pay fees by February 26 2010 ($260.00)

Accompanied by a Preceptor LATE REG. FEE must register and pay fees between Feb. 27 and March 4 ($315.00)
Residents/Fellows Unaccompanied by a Preceptor must register and pay fees by February 26 2010 ($315.00)

Unaccompanied by a Preceptor LATE REG. FEES must register and pay fees between Feb. 27 and March 4 ($370.00)

Amount:

First Name:

Middle Initial

Middle Name:

Last Name:

E-Mail:

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

Institution Name

Street:

City:

State:

Zip:

Name of Preceptor Attending Conference

Please enter EXACT title of submission (the title will be printed in the conference program booklet EXACTLY as submitted here)

Please enter the name(s) of the author(s) separated by commas. Omit degree designations.

Provide ONE objective pertaining to your presentation topic.

Check ONE of the following practice interest categories for this submission:
Residents/Fellows Accompanied by a Preceptor
Residents/Fellows Unaccompanied by a Preceptor
Name of Roommate(s)

Name of Roommate(s) Institution

Special Instructions/Requests - i.e. - beds/room, sofa sleeper, smoking preference, private room, etc. (Private room requests will be accepted space permitting and residents WILL BE CHARGED for 50% room and tax fees.)

Planned Arrival to facilitate the room reservation process: (Presenters are encouraged to be at the conference by 5 PM on Wednesday, May 5th and expected to be there no later than 8 AM on Thursday, May 6th
Planned Departure - to facilitate the room reservation process.
Payment Options

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:

Hotel reservations for presenters (accompanied by a preceptor) traveling from outside the Omaha/Metropolitan Area will be handled by the conference based on information provided on this registration form. The conference will pay for room fees + tax (up to two nights only). If you are a presenting resident or fellow within the Midwest region accompanied by a preceptor and would like to have a room reserved at the Embassy Suites Hotel (conference host hotel) please complete the conference registration form in it’s entirety including your preferred roommate name(s) in the space provided and the dates that you will be arriving and departing the conference. If you are a presenter unaccompanied by a preceptor please refer to the “LODGING & TRAVEL” tab above for additional information. If a preceptor is planning to share a room with a resident, the conference must be notified – please also make note of this request in the “Special Instructions/Requests” section within the conference registration form. Presenters who request a private room will be charged for half of the cost of the room. Private room requests will be accepted space permiting.

mprc

Resident/Fellow