Mail in Registration Form
(print and mail this form)

Name: _____________________________________         Degree:________________
(Please print your name as you would like it to appear on your badge)

Specialty: _____________________________    Affiliation:______________________________________

Guest Name: ______________________________________

Address: ___________________________________________________________________

City: _______________________________

Province or State/Zip:  ____________________________________________________-

Telephone: __________________________

Fax: _________________________

E-mail: ____________________________________

Registration Fees
                                                                Before 7/1    After 7/1

Physician                                                     $350                 $400            __________

Resident                                                        $50                 $100             __________

Nurse/Physicians assistant                            $150                 $195             __________

Friday Box Lunch                                                    __ Yes      __ NO     ___ VEG
Friday banquet (boat leaves at 5:00 pm)
# of Tickets Adults/Children                        #A______________  #C___________
Saturday Box Lunch                                                    __ Yes      __ NO     ___ VEG
Saturday Golf Tournament
&75 ea. (U.S.) (includes cart)                       #_________                        $_________

Total                                                                                                          __________

Make Checks payable to Washington State Dermatology Association  and send to WSDA, 2033 Sixth Ave., Ste. 1100 Seattle WA 98121
(In US dollars only. Credit cards and cash not accepted)

Cancellation Policy: $50 will be retained to cover administrative costs. To receive a refund, written notice must be postmarked no later than July 1, 2007. Refunds will not be available after this date. Although WSDA will make every effort to adhere to the listed programs, WSDA reserves the right to cancel or substitute program speakers. WSDA also reserves the right to modify or cancel a tournament in the event there are not enough participants. If canceled, all entry fees will be refunded. I have read, understand, and agree to the general conditions and cancellation policy.

Signature: _________________________________________   Date: _____________________