Pre-Registration - By Mail


Pre-registration by mail with payment by check or money order must be postmarked by 
11/01/10.  To register by mail, print out this form, complete it and mail it along with a check
payable to the "PSRC SE District Seminar" to:

PSRC SE District Seminar
c/o 225 Hampshire Drive
Sellersville, PA 18960-2876


Name_________________________________      Credentials _________________

AARC Membership #_____________________  (if non-member, write NON-Member)
    (if you don't know your number, send an email to ExecutiveDirector@psrc.net )

Address___________________________________________________________

City _______________________________ State___________ Zip_____________

Telephone (Day) ___________________ E-mail ____________________________

Hospital Affiliation__________________________

Registration Rate                AARC Discounted Member Rate  (must provide valid AARC membership #)
........$45.00................................................$25.00   .

For more information or questions regarding this event, send an email to ExecutiveDirector@psrc.net