February 2005 Frontline - Commissioned Officers Association
February 2005 Frontline - Commissioned Officers Association
February 2005 Frontline - Commissioned Officers Association
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<strong>2005</strong> Public Health Professional Conference Registration<br />
<strong>2005</strong> Global Health Summit<br />
June 6-9, <strong>2005</strong><br />
Philadelphia, Pennsylvania<br />
Please Print Clearly<br />
Member #<br />
Register online at: www.coausphsconference.org<br />
Duty Station City/State<br />
Rank<br />
First Name<br />
Last Name<br />
Profession (Category):<br />
Dentist<br />
Dietitian<br />
Engineer<br />
Environmental Health<br />
HSO<br />
Nurse<br />
Mailing Address Home Business Agency:<br />
AHRQ<br />
ATSDR<br />
BOP<br />
CDC<br />
SAMHSA<br />
Academic<br />
Other<br />
Phone:<br />
Email:<br />
Fax:<br />
Public Health Professional Conference Fees<br />
Member<br />
Junior Officer<br />
Retired Member<br />
Inactive Reserves<br />
Non-Member<br />
Full Conference Rate<br />
Early Bird<br />
(by April 5)<br />
$375.00<br />
$290.00<br />
$290.00<br />
$290.00<br />
$485.00<br />
Global Health Summit Fees<br />
Standard Rate<br />
<strong>Commissioned</strong> Officer Rate<br />
Discounted Rate for attending<br />
both conferences<br />
Payment Info<br />
$__________ Conference Fee<br />
$150.00<br />
$100.00<br />
$125.00<br />
Standard<br />
(after April 5)<br />
$460.00<br />
$350.00<br />
$350.00<br />
$350.00<br />
$570.00<br />
Early Bird<br />
(by April 5)<br />
$145.00<br />
$110.00<br />
$110.00<br />
$110.00<br />
$160.00<br />
Pharmacist<br />
Physician<br />
Scientist<br />
Therapist<br />
Veterinarian<br />
Other<br />
FDA<br />
HRSA<br />
IHS<br />
NIH<br />
Local Agency<br />
State Agency<br />
I plan to attend the Meet and Greet Reception<br />
I plan to attend the Closing Dinner<br />
One-Day Rate<br />
Standard<br />
(after April 5)<br />
$165.00<br />
$125.00<br />
$125.00<br />
$125.00<br />
$190.00<br />
Questions?<br />
Call or email:<br />
866-544-9677 (toll-free)<br />
info@coausphsconference.org<br />
Credit Card #<br />
Check Days Attending<br />
Conference:<br />
Jun 6 Mon, Scientific Program<br />
Jun 7 Tue, Category Day<br />
Jun 8 Wed, Scientific Program<br />
Jun 9 Thu, Scientific Program<br />
Global Health Summit:<br />
Jun 5 Sunday<br />
Students: Log on to our web site for<br />
special student rates.<br />
Special accommodation or diet<br />
needs: Log on to our web site to<br />
notify us.<br />
$__________ Global Health Summit Fee<br />
$__________ Total Payment Enclosed<br />
Expiration Date:<br />
Cardholder Name:<br />
Card Verification Code:<br />
Make Checks Payable to: Public Health Conference Card Billing Address: Zip:<br />
Method of Payment:<br />
Signature of Cardholder:<br />
Check Govt PO Discover<br />
Visa MasterCard American Express<br />
Payment must be enclosed by date indicated to earn rate. Rates include a nonrefundable $35 processing fee. Returned checks incur a $35 fee.<br />
Cancellation Policy: Requests must be received IN WRITING by May 19, <strong>2005</strong>. Refunds for cancellations after May 19 cannot be considered.<br />
Mail Registration to: Public Health Conference, c/o Leading Edge Marketing and Planning Inc, PO Box 1087, Severna Park MD 21146<br />
Fax Registration to: 410-544-6395<br />
COA FRONTLINE • FEBRUARY <strong>2005</strong> 11
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