Registration Form Participant Registration fees Method of
Registration Form To be sent before April 1st, 2015 to [email protected] and suzanne@ipna-‐online.org Participant TITLE: FIRST NAME: LAST NAME: DEGREE: E-‐MAIL (compulsory): PHONE: @ ADDRESS: ZIP CODE: CITY: STATE/PROVINCE: COUNTRY: MEMBERSHIP: ASPN ALANEPE AFPNA ANZPNA AsPNA ESPN IPNA JPSPN Registration fees Conference fees and meals USD 400 Accompanying person (meals) USD 200 TOTAL = USD Method of payment BY CREDIT CARD: VISA / EUROCARD / MASTERCARD AMERICAN EXPRESS I the undersigned to debit the sum of USD on my credit card Card Number Expiration date (card holder’s name) authorise IPNA / CSC (Card Security Code) BY BANK TRANSFER: Banking charges stay at your charge. Please send along with your form a copy of the wire transfer order. Wire to Bank of America Westwood Village Branch 930 Westwood Blvd. Los Angeles, CA 90095 Routing No. For credit to 122000661 International Pediatric Nephrology Association Address C/O Childrens Mercy Hospital Dr. Warady 2401 Gillham Road Kansas City, MO 64108 Account No. 0000-‐9924-‐3104 Swift/IBAN BOFHAUS3N BY CHECK IN USD, please make check out to "International Pediatric Nephrology Association" and mail it to Suzanne Conley Division of Pediatric Nephrology – IWDN registration 10833 Le Conte Avenue, A2-‐383 MDCC Los Angeles, CA 90095-‐1752, USA V alidation Date (DD/MM/YYYY) / PRINT / SEND BY EMAIL
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