Sixth Annual 340B Coalition Conference

Grand Hyatt Washington
Washington, DC
July 15-17, 2002

340B HOME

340B MEMBER REGISTRATION FORM

* You have indicated that you work for a non-profit health care provider or government agency that is a member of the 340B Coalition. (if this is not the case, please click the "back" button on your browser and select the correct registration form).

Providing Contact Information (Step 1 of 2)

Required fields are indicated with red asterisks (*). Please check to make sure that your e-mail address is entered correctly. When the form is complete, click on the Submit button (if you do not have any information to enter into a required field, just type "NA").

Registration Fee: $495

First Name*
Middle Initial
Last Name*
Academic Degrees*
Job Title*
Department
Division
Organization*
Address*

City*
State*
Country
Zip Code*
If any meeting materials are mailed out prior to the meeting, do you want them sent to a different address?
	If yes, please type the full address here:
Telephone*
Fax*
E-Mail*
Special Needs/Accommodations
Please enter here the name (first and last name) on the check or credit card you will be using to pay for your $495 registration fee:
Continuing education credits are available for pharmacists. Would you like CE Credits?