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Spring Retreat Registration
Registration form for Pharmacists and Technicians Only
Fees include CE and food events
Name tags are required to attend any event
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* Indicates required question
Email
*
Your email
First Name
*
Your answer
Last Name
*
Your answer
Street
*
Your answer
City, St
*
Your answer
Zip
*
(5 digits between 00501 - 89049)
Your answer
Phone
*
(10 digits between 2010000000 - 9899999999)
Your answer
Title
Officer
Board Member
Donor
Other:
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Annual Dues
*
Pharmacist $30
Technician $25
Pharmacist Fees
(Check applicable boxes - Technicians skip to next question)
Fri $85
Sat $200
Sun $65
Technician Fees
(Check applicable boxes)
Fri $50
Sat $150
Sun $40
Additional Comments
Your answer
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