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Directions
Registration Form
Charta Fall Workshop 2001
Date: October 29, 2001 (Monday)
Place: National Institutes of Health - Clinical Center - Building
10 14th Fl. Assembly Hall
(print
out this form and complete)
Name:
_______________________ Organization: ________________________
Home
Address: _________________________________ City _______________
State
_____ Zip ________
Telephone:
(H) ___________________ (W) _____________________
FAX
_______________________
E-Mail
_____________________________
Primary
Population Served __________________________
Type
of Participant Fee (please circle choice)
| Current
Charta Member |
$15.00 |
|
Renewing Member
(previous member in 2000)
|
$
25.00 |
Joining
Member
(not previously a member in 2000)
|
$
35.00 |
| Current
Charta Student Member |
$
8.00 |
Joining
Student Member
|
$
13.00 |
| CEU's
(awarded by ATRA) |
$
10.00 |
| Late
Fee (postmarked after 10/8/2001) |
$
20.00 |
Total Fees Enclosed $ ______
Charta's
EIN - 52-1690908
Note: Parking at the P3 Parking
Garage will be $12 (encourage members to
car pool or take the Metro - Red Line to Medical Center.
For further information about this
conference contact Vanessa Roberts at 703-737-8837 (e-mail - vroberts@co.loudoun.va.us)
or Lucile Lisle at 202-782-9584 (e-mail - lalisle@hotmail.com)
For directions to NIH and information
about the facility contact Michael Duquette at 301-496-5159 (e-mail
- mduquette@nih.gov)
Make check payable to Charta.
Mail completed registration form and check to: CHARTA
C/O Lanette Bethea
2801 Arlington Drive #202
Alexandria, VA 22306
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