Print and Fax to 202-296-2663 or Mail to HSR, Inc. Attn: Conference Registrar
 
Seventh Annual 340B Coalition Conference on Improving Access to Pharmaceutical Care and Ensuring Compliance with Federal and State Laws


Space is limited...so register now!

Registration Form

Required fields are indicated with asterisks (*). Please check to make sure that your e-mail address is entered correctly. When complete, please fax to (202) 296-2663, Attn: Conference Registrar; or call Health Systems Research at (202) 828-5100. If you are paying by check, please make the check payable to HSR, Inc. and mail to:

Health Systems Research, Inc.
Attn: Conference Registrar - 340B Registration Form
1200 18th Street, NW
Suite 700
Washington, DC 20036
* Please indicate your registration status below by placing an "X" in the appropriate box:
I am a provider or government employee in the 340B Coalition
(if you aren't sure if you are a member, CLICK HERE to see a list of current members).		  
I am a provider or government employee not in the 340B Coalition.  
I am with a company or organization representing industry (Manufacturers, Wholesalers, Consultants, Pharmacy Service
Companies, Law Firms and Other Businesses).		  
Your Contact Information:
First Name*  
Middle Initial  
Last Name*  
Academic Degrees *  
Job Title*  
Department  
Division  
Organization*  
Address*  
 
City*  
State*  
Country  
Zip Code*  
Telephone*  
Fax*  
E-Mail*  
Special Needs/Accommodations:  
Continuing education credits are available for pharmacists. Would you like CE Credits?  


BILLING INFORMATION (Please base your payment amount on your registration status)

I will be paying by: (circle one)
CHECK CREDIT CARD
Payment Amount: (circle one)
$550
(member provider/government)		 $650
(non-member provider/government)		 $1,250
(industry)
Name as shown on card:  
Billing Address (if different than above)  
City, State, Zip  
Credit Card Type*  
Credit Card Number*  
Credit Card Expiration (mm/yy)*  

*please make checks payable to HSR, Inc.

The registration fee is refundable up to June 11th. All requests for a refund prior to June 11th will receive a full refund. There will be no refunds on registration fees after June 11th although you can send a replacement from your organization or company.

Should you have further questions regarding your registration payment process, please contact:

Conference Registrar
Health Systems Research, Inc.
Phone: (202) 828-5100
Fax: (202) 728-9469
E-Mail: register@hsrnet.com

For any other questions, please contact:


Allison Chapman
340B Coalition
E-Mail: allison.chapman@ppsv.com
Phone: (202) 872-6774

Please Note: For your records, Health Systems Research's (HSR) Federal tax ID# is 52-1353811.