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Registration Form, 2010 CA-NV ACHSA Conference (co-hosted by the Institute for Medical Quality)

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Please complete this application, print it, and mail it with your fee to the address below:

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ACHSA/IMQ 2010
PO Box 1511
Folsom, CA 95763

Make checks payable to: CA/NV ACHSA Conference 2010

non-profit Tax ID # 943117900

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Registration fees:

• CA-NV ACHSA member: $145.00;
• Non-member: $205.00
• One day registration: $115.00

Name
Job Title
Affiliation
Daytime Phone No.
Mailing Address
City
State & Zip
Email Address
Check here if a vegetarian diet is required

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Cancellation Policy

Cancellations must be made in writing or faxed by close of business on August 25, 2010 in order to receive a refund minus a $50.00 processing fee. NO REFUNDS wil be made for cancellations after this date; however, substitutions are permitted when the registrant is unable to attend. If paying by purchase order, payment OR proof of purchase order must be received by the registrar prior to the conference start.

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Please Note: Hotel accommodations are not included with conference registration. Please contact the Crowne Plaza Hotel, San Diego directly at (888) 233-9527.
Make reservations BEFORE August 25, 2010 to take advantage of special group rates!
Click HERE to book your room online!

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