11th Annual Technicians in Action Conference Registration Form

Notes:

You may pay by:

For cheque and credit card payments:

Krista Ryan
Pharmacy Services, Victoria Hospital
London Health Sciences Centre
800 Commissioners Road East, PO Box 5010
London, ON
N6A 4G5

f. 519-685-8604


Name*
Address*
E-mail*

* Required fields.

Are you a CAPT member:

Yes ($50 fee)
No ($55 fee)

How did you find out about the conference?

Type of practice:    
Community Name of Pharmacy: Shoppers
DRUGStore Pharmacy
Rexall PharmaPlus
Walmart Pharmacy
Zellers Pharmacy
Other Pharmacy :
Hospital Name of Hospital:

Bluewater Health
Chatham-Kent Health Alliance
Grey Bruce Health Services
London Health Sciences Centre
St. Joseph's Health Care, London
St. Thomas General Hospital
Stratford General Hospital
Strathroy Middlesex General Hospital (Middlesex Hospital Alliance)
Woodstock General Hospital
Windsor Regional Hospital/Hotel Dieux
Other Hospital:

Payment method:

Cost centre (LHSC registrants only)
Cheque (print this form and send to Krista Ryan at the address above)
Credit card (print this form and send to Krista Ryan or fax to 519-685-8604)

Please print clearly:

Card Type (circle one):
American Express Mastercard Visa
Name as displayed on the card:

 

 

Expiry date:
Month___/Year____

 

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Confidentiality Notice: Any other distribution, copying or disclosure is strictly prohibited.