Registration Options

ACPN 2014 MAIL/FAX REGISTRATION FORM

ACPN West Coast Regional Conference

September 13-14, 2014

Symptom Validity Assessment: Implications for Practice, Ethics & Supervision

REGISTRATION:  Please Print this Page for use with Fax or Mail Options.

General Registration fee (Includes Refreshments and Day-1 Deli Lunch, Day-2 Lite Breakfast.)

 Professionals (Psychologists and Physicians Only) =  $295

 ACPN Fellow or Affiliate*                                    =  $260

 Student                                                            =  $70

 Student ACPN Affiliate*                                      =  $55

 Stay & Network—Sunday Brunch at Old Ranch      =  $30

Discount 10% if registering before 07/12/14, OR if registering 4 or more with the same payment submission by 08/10/14.

Yes, you may complete an ACPN Affiliate application, pay that fee, and take the Affiliate discount, above.

  Subtotal                                                             = $ _________

 Ted Blau Fund Donation (Student Scholarship Fund)  = $ _________

                                                            Total     $ _________

 Conference Registration and Payment Options

    1. www.acpn.myshopify.com (Register online)
    2. Use your PayPal account and pay amount to www.abn.treasurer@gmail.com
    3. Fax the registration form and credit card information to Dr. Gant:  719-218-9003
    4. By USPS mail to:   Bob Gant, PhD, PO  Box 2160, Boulder, CO 80306

          Make checks payable to:  “ABN”

      1. Fax or Online only (no mail) after 09/01/14.
      2. On-site if limited seating is available.

____ My attached check for registration & session choices is payable to "ABN."

____ I am sending registration & credit card information below so you may charge the amount to that card. 

____ I am sending my registration & have paid on PayPal (paid to abn.treasurer@gmail.com)

Circle:   Visa  -  Mastercard  -  Discover  -  AmExpress

Name as it appears on card:

Number:

Expiration Date:                                                   Security Code:

Authorizing signature:

Title/Degree:

Address:

 

City/State/Zip:

Email:

Phone:

 Cancellation Policy  A 60% refund is possible for written cancellation requests postmarked and mailed by Aug 10, 2014 to:  Bob Gant, PhD, PO Box 2160, Boulder, CO 80306.  Cancellations cannot not be accepted by fax or phone. Refunds will not be issued for requests postmarked after Aug 10, 2014.