Click here to download a fax/mail version

Registration Form
Practice-Based Evidence
Another Side of the Knowledge Development Coin
October 24, 2007   Omni Shoreham Hotel, Washington, D.C.

Confirmation and Mailing Information
(Please provide your name as you wish it to appear on your badge)

First Name:		Last Name:
Title:		Professional Designations:

Organization:
Address:

              
City: State: Zip:

The Above address is my  (choose one)        Home        Work

Phone: Fax: E-Mail:

Special Needs: Please indicate if you have any special needs and a staff member will contact you to arrange accommodations.

I am willing to review abstracts for the 2008 State of the Science Congress.

Registration Fees                                  

April 2-September 1
CANS Member	$250	Non-Member	$325
CANS Student Member	$175	Student Non-Member	$225

                                             

September 2-October 1
CANS Member	$275	Non-Member	$350
CANS Student Member	$200	Student Non-Member	$250

                                                                                                                                                                                                             
Registration Total:    

Method of Payment
MasterCard            Visa       Check (Payable to the Council on the Advancement of Nursing
                                                                       Science (CANS) – please write name of registrant on check.)

Name on Card:
Card Number:
Expiration Date	Month: — Jan Feb Mar April May June July Aug Sept Oct Nov Dec Year: — 07 08 09 10 11 12 13

Mail to: Council for the Advancement of Nursing Science, Special Topics Conference Registration, 555 East Wells Street,
Suite 1100, Milwaukee, WI 53202-3823

Fax: 414-276-3349

Registration conformations will be mailed to fax/mail registrants who register before October 1, 2007.