Veteran Affairs Physician Assistant Association, Inc.

Conference Registration Form

Name:
   
Facility:
   
Facility Address:
Facility City:
 Facility State: Facility Zip:
Facility Telephone: Ext:
   
Work Email:
   
Home Address:
Home City:
 Home State: Home Zip:
Home Telephone: Home Email:
   
Cell Phone: (will aid us in finding you at the conference)

Please mark one for registration type:

. ** Must be a Fellow Member of any constituent chapter of AAPA
I am a member of chapter with member number

VISA
MASTERCARD
___ Sorry, NO Am Express

Name on credit card (must be exactly as it is on your card)

Credit card number Secure three (last three digits on back of card)

Expiration date    (Mo-Yr) or (Mo-Da-Yr)          Amount $

 
Dinner Amount: (for # of people)   $
   
Conference Fee Amount:        $
   
Total Conference Fee on Credit Card          $


To print to your slave or default network printer for your copy

(Print your form first if you want a copy for your files, then hit the submit button to send to VAPAA.)

Press only once to avoid duplicate submission When you've completed sending to us, Reset the form to insure your information is safe.

If you prefer to mail or eMail in your fees, you may print this page and mail to:

SEND PAYMENT TO:  MAIL: VAPAA, 1150 North Loop 1604 West, Ste 108, Box 406 San Antonio, Texas 78248
(please include check for full amount)

Or   Email: Conference@VAPAA.org (MUST include all credit card information as above)

(ONLY credit card payments may be Emailed.)

CONFERENCE HOTLINE... 1-866-828-2722 (ONLY available up to one week prior to conference, NOT during the conference.)

Thank You for attending the Conference!

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