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Summer C.E.
August 2010
Pharmacy & Government
Conference Registration Form
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UPhA Member Pharmacist
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$160.00
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Name:
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UPhA Member Technician
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$95.00
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Address:
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Non-Member Pharmacist
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$310.00
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City:
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Non-Member Technician
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$145.00
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State:
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E-Mail:
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Students (Currently Enrolled)
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FREE
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Zip:
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Phone:
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Spouse / Guest (No C.E. given)
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$50.00
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Send Registration form and check payable to:
Utah Pharmacists Association (UPhA)
1125 S. Blackhawk Blvd. Suite B
Mt. Pleasant, UT 84647
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To Pay with Credit Card, include #, Exp. Date, and Sec. Code below
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Card # Exp. Date:
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Signature Sec. Code:
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Note: Registrations include lunch and breaks. Those received after August 10th will incur a late fee of $15.00.
Refunds will be made if we are notified prior to Monday, August 16th, 2008, after which there will be no refunds.
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Amount Enclosed
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$
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Membership is for paid dues within the last 12 months. Please copy application where needed.
Each Respondent MUST complete a separate form.
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