NBNA 33^rd Annual Institute and Conference

Speaker Registration Form

Please type or print:

Name: __________________________________________________________________________

Degree(s): _______________________________ NBNA Member: ___________ Yes _________ No
                      (i.e., RN, PhD, FAAN, etc.)

Title/Agency: _____________________________________________________________________

Address: ________________________________________________________________________

City __________________________________State ________ Zip __________________________

Phone: ____________________ Fax: ___________________ E-Mail: _______________________

Home Phone: ___________________________________ Home Fax: ________________________

Date of Presentation: ______________________________

(Please Check One)

I will attend ONE day only ________
I plan to attend the entire Conference _________
(Enclosed is my discounted Conference registration fee of $175.00)

Guests are non-nurses and may be registered at the $150 rate.

Names:                                                               Age:

______________________________________ ____________

______________________________________ ____________

I require additional meal tickets _______ Yes _______No
      President's Banquet $80         Sunday Brunch $50        _________ Quantity

ACCOMMODATIONS:
Please check one box:

 I do not require accommodations.
 I will need a hotel reservation. NBNA will reserve a room for each registered presenter based on the     information provided below. NBNA will pay one night (Room & Tax ONLY) for out of town presenters.

Arrival date ____________ Departure date _____________

Single-King ______ Double ______ Quad ______ Smoking _______ Non-Smoking ________

AIRLINE (Presenters are responsible for air travel)