HOTEL REGISTRATION FORM
5
TH
Annual Convention of the Association of Nigerian Physicians in the Americas
PUBLIC HEALTH
June 23-27, 1999 · Las Vegas, NV
Phone: (909) 780-2504 · Fax: (909) 780-8083 · Website: http://www.anpa.org
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ROOM RESERVATION CARD
(ONE ROOM PER CARD) PLEASE PRINT
RIVIERA HOTEL & CASINO
NAME __________________________________________________
ORGANIZATION __________________________________________
STREET ADDRESS
______________________________________
CITY ___________________________ STATE _____ ZIP ________
ARRIVAL DATE _____________ DEPARTURE DATE ____________
All Reservations must be recieved by 5/23/99
and accompanied by a one-night room & tax deposit.
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Check Enclosed
Please charge my:
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American Express,
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Diners Club,
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MasterCard,
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Visa for one night and tax deposit
Card Holder__________________________________________ Phone (______) ______________________________
Card # ____________________________ Exp. Date ____________ Signature ________________________________
ASSOCIATION OF NIGERIAN PHYSICIANS IN THE AMERICAS
June 23-27, 1999
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Single - $99.00
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Double - $99.00
+ $20.00 Each Third or Fourth Person
Bed Preference
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King
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2 Doubles
SUITES
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Petite
$150.00
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1-Bedroom
$200.00
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2-Bedroom
$275.00
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1-Bedroom Penthouse
$500.00
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2-Bedroom Penthouse
$600.00
ROOM RESERVATIONS (800) 634-6753
FAX (702) 794-9451
Welcome
**ASSOCIATION
WILL NOT PAY
FOR SUITES
All reservations subject to 9% room tax
and suites subject to confirmation.
Check In - 4 pm
Check Out - Noon
Name ________________________________________________________
Last Name
First Name
MD/DDS/DO/Other (please indicate)
Address _______________________________________________________
______________________________________________________________
Office Phone( )_____________________________________________
Home Phone( )_____________________________________________
Fax( ) ______________________________________________________
Accompanying Spouse________________________________________
Last Name
First Name
Dr./Mr./Mrs.
Interested in Auxiliary Sessions: t yes t no
include $50 annual membership dues
If registering by credit card, complete the following:
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Amount ______________ Exp. Date: ____________
Card #______________-______________-_____________-_____________
Signature: ____________________________________________________
MEETING REGISTRATION FORM
5
TH
Annual Convention of the Association of Nigerian Physicians in the Americas
PUBLIC HEALTH
June 23-27, 1999 · Las Vegas, NV
Phone: (909) 780-2504 · Fax: (909) 780-8083 · Website: http://www.anpa.org
REGISTRATION FEES
Please Check Which Apply
t Physicians/Dentists (Member) . . . . . . . . . . . . $250
t Physicians/Dentists (Non-member) . . . . . . . . $350
t Physicians/Dentists (From Nigeria) . . . . . . . . . $100
t Physicians/Dentists (From UK, Middle East etc.) . . . $150
t Fellows, RNs, Pharmacists, PAs . . . . . . . . . . . . $100
t Residents, Interns . . . . . . . . . . . . . . . . . . . . . . . $ 50
t Students/Invited Guests . . . . . . . . . . . . . . . . . N/C
t Others . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $100
Registration Deadline:
May 30, 1999
Send check or FAX Credit Card Information to:
ANPA, Inc.
4000 14th Street, Suite 401
Riverside, CA 92501-4010
FAX: 909/780-8083
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