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


Space is very 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: Martrell Kelly; 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: Martrell Kelly - 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  
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*  

If materials are sent out prior to the conference, do you want them sent to a different address?

If so, enter the full address here:

  
Special Needs/Accommodations:  


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)
$450
(member provider/government)		 $550
(non-member provider/government) 		$995
( 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.

Please Note: For your records, the National Association of Public Hospital's (NAPH) Federal tax ID# is 52-1236600
(NAPH is the organization that will be receiving payments for this conference)
 
Location & Accommodations

The meeting will be held at the Loews L'Enfant Plaza Hotel in Washington, DC. A limited number of rooms have been reserved at a reduced rate until Monday, June 18th. The reduced rate is $159.00 (plus appropriate taxes) per night. Rooms reserved after June 18th will be on a rate and space availability basis. Please mention the 340B Coalition Conference to receive the reduced rate.

Reservations should be made by phone upon receipt of your registration confirmation e-mail and your registration payment submission. Please call the hotel directly to make your reservation, as you will not be able to receive the special rate if you make your reservation online.

Loews L'Enfant Plaza Hotel
480 L'Enfant Plaza, S.W.
Washington, D.C. 20024
Phone: 202-484-1000
Fax: 202-646-4456