Class A/Retired Registration Form

Class A/Retired Registration Form
Please fill out this form completely so that we can update our records. We are not yet able to accept credit cards online, so it is very important that you send in a check for your membership fees. Your registration process will not be complete until we receive your check.

Please make checks payable to Wisconsin Perfusion Society.
You will need to submit a $10 check (the spring meeting is included!) to:
If bringing additional guest to Friday dinner, please include $30 extra per guest.

Anna R Young CCP
2155 Green Ridge Rd.
Oregon, WI 53575-2264
Membership Deadline: March 12, 2010
Meeting Registration Deadline: March 12, 2010
(There will be a $25 late registration fee after this date.)

Demographics * First Name
* Last Name
  Middle Initial
* Email Address

* Street Address

* City
* State
* Zip Code

* Phone Number

2010 WPS Spring Meeting * Would you like to register for the 2010 WPS Spring Meeting held March 26-28? Yes No
* Will You Be Attending the Friday Night Dinner? Yes No
* Will You Be bringing a guest (additional $30)? Yes No

Please Share any Questions or Comments with us:

* indicates Required Field.

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Demographics	* First Name * Last Name Middle Initial * Email Address * Street Address * City * State * Zip Code * Phone Number
*2010 WPS Spring Meeting*	* Would you like to register for the 2010 WPS Spring Meeting held March 26-28? Yes No * Will You Be Attending the Friday Night Dinner? Yes No * Will You Be bringing a guest (additional $30)? Yes No
Please Share any Questions or Comments with us:
* indicates Required Field.