Name _____________________________________________________________________________________________________
Last Name
First Name
MD/DDS/DO/Other (please indicate)
Address ___________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Office Phone( ) __________________________________________________________________________________________
Fax( ) __________________________________________________________________________________________________
Home Phone( )___________________________________________________________________________________________
Email Address ______________________________________________________________________________________________
Accompanying Spouse _______________________________________________________________________________________
Last Name
First Name
Dr./Mr./Mrs.
Interested in Auxiliary Sessions:
yes no
include $50 annual membership dues
If registering by credit card, complete the following:
Amount ______________________ Exp. Date: __________________________________
Card #____________-____________-____________-____________
Signature: _________________________________________________________________________________________________
MEETING REGISTRATION FORM
6
TH
Annual Convention of the Association of Nigerian Physicians in the Americas
June 28-July 2, 2000 · Washington D.C.
Phone: (909) 778-0716 · Fax: (909) 778-0717 · Website: http://www.anpa.org
REGISTRATION FEES
Please Check Which Apply
Physicians/Dentists (Member). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200
Physicians/Dentists (Non-member) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $350
Physicians/Dentists (From Nigeria). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $100
Physicians/Dentists (From UK, Middle East etc.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150
Fellows, RNs, Pharmacists, PAs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $100
Residents, Interns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 50
Students/Invited Guests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Charge
Others. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $100
Registration Deadline: May 31, 2000
Send check or FAX Credit Card Information to:
ANPA, Inc.
6876 Indiana Ave. Suite F
Riverside, CA 92506
FAX: 909/778-0717
