PNWD 88th Annual Scientific Conference Registration Pacific Northwest Dermatological88th Annual Scientific Conference October 7-9, 2022 Suncadia Resort and Spa Cle Elum, WAContact InformationName* First Last Credentials (MD, DO, PhD, etc.) First Name for Badge (If Different than Above) Group / Hospital Name* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands PhoneEmail* Contact Information Sharing By providing your consent, WSDA will only share your name and city with registered exhibitors. None of your other identifying contact information entered on this form will be shared. Registration & Payment InformationConference registration fee includes your three-day conference tuition, e-syllabus, opening night reception, as well as all breakfasts and refreshment breaks. The Saturday Night Dinner Banquet is free for the attendees. Guest are invited to dinner, please register your guest below. Registrant* General Registrant Speaker Board President CONFERENCE REGISTRATION* WSDA Member: - $450.00 Non-Member: - $625.00 Retired: - $300.00 Advanced Practice Clinicians: - $350.00 Resident-Member: No Charge - $0.00 I will be attending the dinner (included with registration) Yes No No. of adult dinner guests:Adult dinner guests are $75.00 eachSelect # of adult dinner guestsOne guest - $75.00 - $75.00Two guests - $150.00 - $150.00Three guests - $225.00 - $225.00Four guests - $300.00 - $300.00No. of child dinner guestsChildren ages 5-12 are $35 each; children under 5 years old are free.Select # of child dinner guestsOne child guest - $35.00 - $35.00Two child guests - $70.00 - $70.00Three child guests - $105.00 - $105.00Four child guests - $140.00 - $140.00Coupon TOTAL $0.00 Payment Type* Credit Card Check Check Number* CREDIT CARD* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month010203040506070809101112 Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Security Code Cardholder Name CANCELLATION POLICY: We must receive written notification of your cancellation. A $50 processing fee will be deducted from the registration refund. No refunds after September 6, 2022. INQUIRIES: Contact Delphi Locey, Association Executive, at the WSDA Office at (206) 956-3650 or send emails to washingtonderm.org. Δ
