<p> Registration for the 2017 Pacific NW Regional Chapter (PANWAT) Conference</p><p>Toxicology Challenges and Applications in Protection of Public Health</p><p>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</p><p>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)</p><p>Name: Title:</p><p>Affiliation:</p><p>Phone: e-mail:</p><p>Address:</p><p>City: State: Zip: Country:</p><p>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:</p><p> Yes, I plan to attend Sunday’s Speed Mentorship and/or Social Reception</p><p> No, I do not plan to attend Sunday’s Speed Mentorship and/or Social Reception</p><p>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)</p><p>Name:</p><p>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 $</p><p>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 $</p><p>Total: $ *Registration includes Sunday social reception & Monday coffee, snacks, & lunch</p><p>Payment Payment Type (check one): [ ] Credit Card [ ] Check [ ] Money Order</p><p>Credit Card (check one): [ ] American Express [ ] Visa [ ] MasterCard [ ] Diners Club</p><p>Charge Amount: $ Account #: Exp. Date:</p><p>Signature: Please make checks payable to: PANWAT Society of Toxicology</p><p>Submission (completed form and payment to)</p><p>Ashley Black PANWAT Registration Society of Toxicology 1821 Michael Faraday Dr, Suite 300 Reston, VA 20190 [email protected] </p><p>Registration confirmation will be sent.</p><p>For questions, contact Nadia Moore ([email protected], 425-556-5555).</p>