Conference Registration Form

Conference Registration Form

(Please print and complete this form and return it via fax or mail.)

Name:
Nickname for Badge:
Title:
Organization:
Mailing Address:
City:
State/Province:
Country:
Zip Code:
Phone:
Fax:
Email:

MEMBERSHIP INFORMATION (You must check one box)

To attend this conference, you must be a current member of InSight or your institution must be a current member of the AdVantage User Group or IMPACT. Current InSight, Advantage User Group and IMPACT membership lists are enclosed. If you would like to become a member of InSight or to renew your InSight membership, please complete the enclosed application and include your $50 membership fee with your conference registration fee in order to attend the conference. To become a member of IMPACT, call Jack Sirabian at 847/570-8820. To become an AdVantage member, call Beverly Fromm at 219/482-5834. All those affiliated with Pathlab must become an InSight member by completing the InSight membership aplication.

Current Member (1999 Dues Paid)
(1) 1999 InSight Active Member
(2) 1999 InSight Consultant Member
(3) 1999 AdVantage Institutional Member
(4) 1999 IMPACT Institutional Member
1999 InSight Affiliate Member
(5) Partner
(6) Business
(7) Associate
New Member or Renewal of InSight Membership
(8) New (or renewal) InSight Active Member (You must attach membership application) - $50 Fee
(9) New (or renewal) InSight Consultant Member (You must attach membership application) - $50 Fee
Prepay InSight Membership for the Year 2000
(10) If you would like to prepay your 2000 Active or Consultant InSight Membership Fee, check this box also (You must attach membership application) - $50 Fee

TOTAL MEMBERSHIP FEE (If Applicable) $

REGISTRATION FEES
(11) Conference Fee:	$600	$
(12) Pre & Post Conference Workshops (You MUST attach Workshop Registration Form)	Total from Workshop Form	$
(13) Special Event Fee for Guest (Guest's Full Name: )	$50	$
TOTAL REGISTRATION FEES $

TOTAL FEES (Add Membership Fee (if applicable) & Total Registration Fees) $

DISCOUNTS & CREDITS
(14) Early Registration Discount (REGISTRATION FORM MUST BE POSTMARKED PRIOR TO 8/1/99)	($105)	($ )
(15) Speaker Credit (Attach Credit Voucher)		($ )
(16) Committee Incentive Credit (Attach Credit Voucher)		($ )
TOTAL DISCOUNTS & CREDITS ($ )

AMOUNT DUE (Subtract Total Discounts & Credits from Total Membership & Registration Fees)
$

PAYMENT METHOD (Please check one box)
NOTE: To be considered registered for the conference, full payment must accompany your completed registration form. If registration and full payment are postmarked prior to 8/1/99, a confirmation of your registration will be mailed within seven (7) days of receipt. Sorry, payment vouchers are not acceptable.
(17) Check - Payment Enclosed - Make check payable to InSight and mail with this form and any applicable attachments to InSight, PO Box 3867, Frederick, MD 21705.
(18) Credit Card (Check One) AMEX MasterCard VISA Expiration Date: Credit Card Number: Card Holder Name: Signature: ___________________________________ Fax credit card registrations and any applicable attachments to 301/694-5124 or mail to InSight, PO Box 3867, Frederick, MD 21705.

IMPORTANT

(19) If you are a McKessonHBOC employee or Pathfinder award winner and McKessonHBOC is paying your registration fee, you must send this completed form to Becky Chaussinand at McKessonHBOC, 5995 Windward Parkway, Alpharetta, GA 30005.

CANCELLATION POLICY

Registration fees less a $50 cancellation fee will be refunded only if written cancellation is received before 8/6/99. Fax your cancellation notice to 301/694-5124. Membership fees are non-refundable.