Registration Form

Registration Information

First Name

Middle Initial

Last (Family) Name

Nickname for Badge

Job Title

Organization

Address

City

State

Zip

Country

Phone

Fax

E-Mail Address

Highest Academic Degree

Emergency Contact Name

Emergency Contact Phone Number

The information above is new or has changed.

I will require special services in accordance with The Americans with Disabilities Act .

Primary Business/Industry (Check only one)

Contract/Clinical Research (a)

Analytical Testing Lab (b)

Government (c)

Academia (d)

Manufacturing (e)

Publications (f)

Cosmetics (g)

Foods (h)

Medical Devices/Diagnostics (i)

Biotechnology (j)

Materials Manufacturing (k)

Association (l)

Other (m)

Purchasing Authority (Check only one)

Recommend (a)

Specify (b)

Authorize (c)

Purchase (d)

None (e)

Registration Fees (Choose one)

AAPS Member

(AM) $700

(OM) $815

Non-Member

(AN) $1,050

(ON) $1,225

AAPS Member (Government)

(AGM) $200

(OGM) $250

Non-Member (Government)

(AGN) $200

(OGN) $250

AAPS Member (Student)

(AS) $55

(OS) $65

Continuing Education

Continuing Education

(CE) $30

New Membership

AAPS Membership (Regular)

(DM) $110

AAPS Membership (Student)

(SM) $30

Payment Method

AAPS does not accept government training forms. Federal Tax ID: 521444968

Check #

Payable to: AAPS/Management Seminar US dollars, drawn on a US bank

Charge**

Visa

MasterCard

AMEX

Discover

Card Number

Expiration Date (Required)

Cardholder Name

Until you receive a confirmation letter , your registration is not complete. You should receive it 5-10 business days after your payment is received. If not, call 703-248-4787. Cancellations must be received in writing by January 4, 2002 . All refunds will be issued after the meeting has occurred.

Questions? 703-243-2800