PNWD 85th Annual Scientific Conference Registration Pacific Northwest Dermatological 85th Annual Scientific Conference July 20-22, 2018 The Coeur d'Alene, Coeur d'Alene, IdahoName First Last TitlePreferred First Name for BadgeGroup NameAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country PhoneEmail* (Email address is required to receive a confirmation/receipt and your e-syllabus) Conference 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. Conference RegistrationConference Registration RatesMember - $400.00Non Member - $625.00Retired - $250.00Advanced Practice Clinicians - $325.00Residents - No chargeI will be attending the dinner (included with registration):YesNoNo. of adult dinner guests:Adult dinner guests are $75.00 eachSelect # of adult dinner guestsOne guest - $75.00Two guests - $150.00Three guests - $225.00Four guests - $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 - $35.00Two child guests - $70.00Three child guests - $105.00Four child guests - $140.00Optional - Saturday Family Activity Raptors are fascinating birds: the silent night-hunting owls, the day-hunting hawks, the fish eating ospreys, the fast flying falcons, and the mighty eagles. Birds of Prey Northwest will provide an educational program, bringing in a raptor biologist with 5 glove handled raptor species-including an eagle!Adult Tickets - Saturday Family ActivityAdult tickets $20.00 eachSelect # of adult ticketsOne guest - $20.00Two guests - $40.00Three guests - $60.00Four guests - $80.00Child Tickets - Saturday Family ActivityChildren ages 5-12 are $10 each; children under 5 years old are free.Select # of child ticketsOne child ticket - $10.00Two child tickets - $20.00Three child tickets - $30.00Four child tickets - $40.00TOTAL $0.00 CREDIT CARD American ExpressDiscoverMasterCardVisa Card Number Expiration Date Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Security Code Cardholder Name