Conference Registration

Five Easy Ways to Register:

Call:        June Portnoy at 1-888-364-3544, ext. 228
E-mail:    jportnoy@engelpub.com

Fax:         Print Ready Form to 215-867-0053

Mail:          Pharmaceutical Media Group

               828A Newtown-Yardley Road

               Newtown, PA 18940

Online:     www.patientcenteredmarketing.com

Please check registration desired

DELEGATE FEES

Registration Costs:

$1,895

Team Registration
(Take 15% Off Each Additional Delegate)

See Below

Academic Registration
(Must request on university letterhead)

$1,195

Government Registration
(Must request on official government letterhead)

$ 895

Team Registration
Save 15% off third and each additional team member registered at the same time from the same corporation, at the applicable rate. Team discount is not available with advance registration rates.

For information on registration please call Christine Guadet, toll-free, at 888-364-3544, ext. 270

First Name: *
Last Name: *
Title: *
Department *
Company: *
E-mail Address: *
Telephone: *
Fax:
Address 1: *
Address 2:
City: *
State/Province: *
Zip Code: *
Country: *

Special Dietary Restrictions:

Please tell us how you heard about Engel Conferences:
* Engel Conferences reserves the right to determine registration type and qualifying rate

Name of 1st registrant:
Title of 1st registrant:

Name of 2nd registrant:
Title of 2nd registrant:

Name of 3rd registrant:
Title of 3rd registrant:

Name of 4th registrant:
Title of 4th registrant:

Name of 5th registrant:
Title of 5th registrant:

All registrants will receive a written confirmation on the receipt of their delegate registration

I am unable to attend, but wish to purchase: document book ($125) access to online presentations ($395) both ($475) I am unable to attend, please put me on your mailing list.


Payment Options (please select one) *
By Check Please make checks payable to: Med Ad Inc. Pharmaceutical Media Group Mail to: Patient-Centered Marketing Conference c/o Canon Communications' Pharmaceutical Media Group 828A Newtown-Yardley Road Newtown, PA 18940

American Express Visa MasterCard
Card Number:
Expiration Date:	/ (mm/yy)
Name as appears on card:
ON RECEIPT, COSTS FOR YOUR REGISTRATION WILL BE CHARGED TO THIS CARD, UNLESS CHECK ACCOMPANIES REGISTRATION. TEAM MEMBERS MUST PROVIDE THEIR OWN PAYMENT OR CREDIT CARD INFORMATION OR ENTIRE TEAM COST WILL BE CHARGED TO THIS CARD. YOU MAY COPY THE REGISTRATION FORM FOR EACH TEAM MEMBER TO FILL OUT AND THEN SUBMIT TOGETHER.

By Fax (download form here, and with credit card info filled out, fax to: 215-867-0053)

Substitution and Cancellation: Please notify us in writing 10 business days before the event start date if, for any reason, you should be unable to attend. A credit voucher equivalent to the amount you paid will then be issued or, if you prefer, a full refund less a $395 non-refundable administrative fee will be given. For cancellations received fewer than 10 business days before the event start date no refunds or credits will be given. Your registration may be transferred to another individual at any time, but please notify us in writing. When registering, please indicate whether you qualify for a discount. No discounts can be combined. Canon Communications' Pharmaceutical Media Group does not accept responsibility for covering travel, accommodation or any other costs incurred by registrants should this event be cancelled for any reason. The event program content is subject to change without notice. Fields marked with an asterisk (*) are required. Press "submit" button to process. You will get a confirmation that your information was received.

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