Advanced HCC Registration Form - Wisconsin Healthcare Engineering Association

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Today's Date*

$275 Registration Fee

Please fill out your Organization Information before adding attendees. You can add up to 10 attendees on this form. Cost of program is $275 per registrant.

Organization*

WHEA Chapter*

If you have paid dues to a WHEA Chapter, please choose which one. If you don't know, just choose "Not a WHEA Member".

Address*

Street Address City State Zip

Contact Email*

Work Phone*

Payment Option*

Please provide P.O. Number:*

Comments

Indicate special needs that you might want us to know about. ( i.e handicap access, Food Allergies, etc)

Product Name*

Price: $275.00

Gift Certificate #:

Attendees

Name	Title	Email	Phone	Actions

There are no Attendees.

**PLEASE NOTE: ** You must fill out your organization info before adding attendees or this will result in an error.

If payment is to be made by Check or P.O. number, return a copy of your invoice page with check payable to WHEA and mail to:

Wisconsin Healthcare Engineering Association
WHEA
11801 W Silver Spring Drive
Suite 200
Milwaukee, WI 53225

info@whea.com

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Credit Card

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Note: See website for further information on updated cancellation rules and cancellation fees. All registration fees must be paid in advance.

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