Home > Activities > Annual Symposium > Registration 2012 Symposium Registration To register for the 2012 NERHRT Symposium, please complete one of the forms listed below. Use Registration Form 01 to pay offline by mail Use Registration Form 02 to pay online with credit card For more information, please contact Marion Pawlek at 603-643-2800 or . Registration Form 01 (Complete this form to pay offline by mail) * Required Full Name * Title & Credentials * Organization * Mailing Address * City * State * Zip * Phone * Email * Individual Registrant (please select one) Full conference (October 25-26, 2012) Student Rate: $50.00 Member Rate: $120.00 Non-Member Rate: $145.00 Thursday only (October 25, 2012) Student Rate: $25.00 Member Rate: $50.00 Non-Member Rate: $60.00 Friday only (October 26, 2012) Student Rate: $50.00 Member Rate: $120.00 Non-Member Rate: $145.00 Questions/Comments (Please list any dietary restrictions) To pay offline (by mail) Registration Form 02 (Complete this form to pay online with credit card) * Required Full Name * Title & Credentials * Organization * Mailing Address * City * State * Zip * Phone * Email * Individual Registrant (please select one) Full conference (October 25-26, 2012) Student Rate: $50.00 Member Rate: $120.00 Non-Member Rate: $145.00 Thursday only (October 25, 2012) Student Rate: $25.00 Member Rate: $50.00 Non-Member Rate: $60.00 Friday only (October 26, 2012) Student Rate: $50.00 Member Rate: $120.00 Non-Member Rate: $145.00 Questions/Comments (Please list any dietary restrictions) To pay online (credit card) to top Copyright ? New England Rural Health RoundTable ?? Design by SeaCoast Web Design