Prime Clinical Systems, Inc
Int and PCM-STAFF SESSIONS
REGISTRATION FORM
Our group would like to register
_____ April 18, 2018
Specialty: _________________
Staff features in Intellect and PCM will be covered!!
Space is limited--Registrations are on a first-come first-served basis!
CLIENT INFORMATION:
Client ID: __________________ CLIENT NAME: ____________________________________
MAIN CONTACT: _________________________________ EMAIL: _________________________
CELL: ________________________ OFFICE: _____________________________________________
# OF ATTENDEES _____________ LOCATION:
Registration fee: $65.00 per attendee Roundhouse Market &Conference Ctr.
Lunch will be provided Shasta Room
Time: 9:00am to 4:00pm 2600 Camino Ramon
San Ramon CA 94583
CREDIT CARD INFORMATION:
VISA______ MASTERCARD______
Amount to be charged: ________________
Credit Card Number: ______________________________________________
Credit Card Expiration: ________________________
Name as it appears on card: ____________________________________
Address where credit card bills to: ______________________________
Signature of Card Holder: _____________________________________________
FAX: Please fax completed form to Armineh Albarian fax# 626-449-0164. Registration fees are non-refundable. If you have any questions about registration, the meeting, or its' content please call Marty Beteta @ 626-449-1705 ext 222.