Registration

Kidney Disease Economics Conference
Balancing Economics & Quality in Renal Care
February 4 - 6, 2005

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Conference Registration - Step 1

If you have already registered, and wish to re-submit payment or review receipt,
enter Last Name: & Invoice #: and
Review / Re-Submit

All fields below are required with the exception of those indicated with *

First Name:

Last Name:

Badge Name (if different)*:

If an entry is made here, your badge will be printed EXACTLY as entered!

Title/Position*:

Department*:

Company / Affiliation*:

Association Code*:
If you are a member of a national renal association, include your ASP code. Contact your Executive Director to see if you are in the Association Subscription Program.

Address:

City:

State: ZIP/Postal Code:

Country:

USA Canada Other

Phone* (including Area Code):

Fax* (Including Area Code):

Email:

Saturday event in which I am interested in participating:
Shopping Tennis Golf	Hiking & Nature Walk None (Separate fees apply)

Professional Title: ( select one)
	Administrator, Manager	Nephrology Nurse
	Medical Director	Dietitian
	Nurse Administrator	Renal Technician
	Transplant Administrator	Social Worker
	Facility Board	Ad Agency
	Facility Owner	Transplant Coordinator
	Chief Technician	Librarian
	Nephrologist	Patient
	Transplant Surgeon	Laboratory Director
	Vascular Surgeon	Network Director
	Internist	Government Official
	Other Physician	Other Title, specify

Facility Type: ( select one)
	In-hospital Clinic
	Free-standing Clinic
	Transplant Center
	Private Practice
	Library
	Manufacturer
	Distributor
	Dealer
	Ad Agency
	Laboratory
	Publisher
	Professional Assoc
	Other,specify

Registration Fee:

NN&I Paid
Subscribers

Non-Subscribers

Regular, November 1, 2004 - December 31, 2004:

Late, After January 1, 2005:

Register NOW for:

$365.00

$425.00

$ 425.00

$435.00

$495.00

$ 495.00

Subscription Account #:

(from magazine cover label)

Method of Payment: Credit/Debit Card Check*

* Registration form and check must be postmarked by Early Registration date to take advantage of reduced rates. Incorrect checks will be returned.

Subscribe to NN&I: (USA)

Professional Rate: $ 55.00 , 13 issues/year*
Patient Rate: $ 27.50 , 13 issues/year*
No, thank you!

* NOW includes online access to nephronline.com


Cancellation Policy:
	Refund for cancellations of registration will be made subject to the following deadline and charges:
	On or before December 4, 2004: After December 4, 2004:	50% of registration fee No refund

All cancellations must be made in writing to Conference Planner and the refund will be made after the Conference. Please note that substitution is permitted on the basis that written notice is given prior to the start of the Conference and any eligibility fee differences are paid.