Regional Chapter Registration Form

Registration for the 2017 Pacific NW Regional Chapter (PANWAT) Conference

Toxicology Challenges and Applications in Protection of Public Health

Sunday, October 1, 2017 Monday, October 2, 2017 Reception/Speed Mentorship Scientific Program Hilton Garden Inn Seattle Genetics 22600 Bothell Everett Hwy 21823 30th Dr SE Bothell, Washington 98021 Bothell, WA 98021

Registration Deadlines: Sept. 3rd (Sunday) – Last day for early-bird registration Sept. 28th (Thursday) – Last day for on-line registration (On-Site Registration available October 1st and 2nd)

Name: Title:

Affiliation:

Phone: e-mail:

Address:

City: State: Zip: Country:

This year’s PANWAT Social Reception is Sunday night following the mentoring session—please be sure indicate your plan for attending Sunday night’s activities:

 Yes, I plan to attend Sunday’s Speed Mentorship and/or Social Reception

 No, I do not plan to attend Sunday’s Speed Mentorship and/or Social Reception

This is the mail-in registration form. Please mail or email a pdf to address on pg 2. Registration for the 2017 Pacific NW Regional Chapter (PANWAT) Conference (continued)

Registration Fees* Early-Bird Registration Fees Registration Fees Member Rates: (by Sept. 3) (Sept. 4 or after) Full $90.00 $115.00 $ Postdoctoral $45.00 $55.00 $ Graduate student $45.00 $55.00 $ Undergraduate student Free Free $

Non-Member Rates: Full $115.00 $140.00 $ Postdoctoral $60.00 $70.00 $ Graduate student $50.00 $60.00 $ Undergraduate student $5.00 $5.00 $ Invited Speakers No Charge No Charge $

Total: $ *Registration includes Sunday social reception & Monday coffee, snacks, & lunch

Payment Payment Type (check one): [ ] Credit Card [ ] Check [ ] Money Order

Credit Card (check one): [ ] American Express [ ] Visa [ ] MasterCard [ ] Diners Club

Charge Amount: $ Account #: Exp. Date:

Signature: Please make checks payable to: PANWAT Society of Toxicology

Submission (completed form and payment to)

Ashley Black PANWAT Registration Society of Toxicology 1821 Michael Faraday Dr, Suite 300 Reston, VA 20190 [email protected]

Registration confirmation will be sent.

For questions, contact Nadia Moore ([email protected], 425-556-5555).