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)

Name:

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).