2017 CHRC Annual Retreat
Registration Form
October 3-4, 2017
Crescent Hotel, Dallas, Texas
Register by Wednesday, August 30, 2017

Fields with * are required.

Contact Details

First Name * :
Last Name * :
Degree :
Specialty :
Institution/Company * :
Country * :
Address * :
City * :
State * :
Zip Code * :
Int'l Phone Country Code :
Phone * :
Email * :
I have special needs (specify) :

Prices

CHRC Presenter
$1,300.00 
Scholar
$1,300.00 
Mentor
$1,300.00 
Principal Investigator
$1,300.00 
Program Director
$1,300.00 
I am a... *


Lodging Options/Preferences

Lodging for 2 night(s) will be included in your registration fee. You will be charged $266.12 for each additional night, calculated based on your dates of arrival and departure.
Arrival Date :      
Departure Date :      
Room Choice :

Options/Preferences

Lunch
Tuesday, October 3, 2017

Dinner
Tuesday, October 3, 2017

Lunch
Wednesday, October 4, 2017

Cancellation Policy

Your registration fee, less a $1,300.00 administrative fee, will be refunded if written notification is received by MedPub, Inc. on or before August 30, 2017. No refunds will be granted after August 30, 2017.
Fax number: 734-699-1136, email: admin@medpubinc.com

Your Order

Total :

10.00

Payment Type :
 

Payment Details

Registrants paying by credit card: Your billing address has to match the address on file with your credit card.
First Name on Card * :
Last Name on Card * :
Billing Country * :
Billing Address * :
Billing City * :
Billing State * :
Billing Postal Code * :
Phone :
Card Type * :
Card Number * :
Exp. Date * :  / 
CCID * : (What is this?)

By clicking the "Submit" button below, you authorize this amount to be charged/billed to you. If you've selected a credit card as your payment method, your card will be charged when you click "Submit".