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New England Coalition for Health Promotion & Disease Prevention

Registration Form

INSTRUCTIONS
Complete the form below and click on "Submit" to send the form via e-mail. Please complete all parts so that we can list you properly on your nametag and in the attendees list, and so that you will receive all post-conference mailings.
 

 I will attend the conference (see payment options below).

  I cannot attend the conference, but please keep me informed of future activities.

Name:
REQUIRED

 

Credentials:
(i.e., MD, RN, PhD)

 

Title:

 

Organization:

 

Mailing Address:

 

City:

 

State:

 

Zip:

 

Telephone (area code):

 

Fax (area code):

 

E-Mail Address:
REQUIRED

 

Special Accommodations:

 

PAYMENT INFORMATION

 I will pay online using a credit card.

 I am sending you my check today for $75 made payable to NECON.

    Check #
    Mail to:
    Necon Annual Conference, c/o Linda Downing, 11 Bens Way, Hopedale, MA 01747

 Please invoice me for $75.

    PO's accepted. NECON's FEID# is 042-632-729
    Invoice department and address if different from above:
     

Please help us control our costs by informing us if your plans change and you cannot attend. No-shows will be invoiced. Cancellations cannot be accepted after December 2, 2008 at 5:00pm.

* Registrations received after the deadline will be accepted on a space available basis, and registrants will not be included in the list distributed at the conference due to printing deadlines.

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The New England Coalition for Health Promotion and Disease Prevention
The Yaffe Foundation 2 Regency Plaza, Apt 912 Providence, RI 02903
Tel: 401.272.5522

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