Event Registration Form

Institute Assessment Institute
Dates January 8-11

Fee including registration, institute materials, and continental breakfasts and lunches.

$675/person

Multiple-person discount:  Fee applies when teams of three or more from the same institution attend an institute.

 $575/person
* denotes a required field  
* Name
* Dept/Discipline:
* Institution:
* Work Phone:
  Home Phone:
  Fax:
* E-mail:
   

For multiple person or group registration, enter a contact person or group representative in the fields at left and the remaining names, one name per line, below:
* Select Event:
     Assessment Institute (January 8-11)
 
* Method of Payment:
     Please bill me. Use the following Purchase Order number:
     A check made payable to "St. Louis College of Pharmacy" is being sent to:

St. Louis College of Pharmacy
4588 Parkview Place
St. Louis, MO 63110-1088
314.367.8700
 
     I am registering as a participant from the host school. My registration is being paid by my institution.
 
* Payment Amount:

Questions/Comments/Reasons for Attending: