Webinar Registration Members - Wisconsin Healthcare Engineering Association

"*" indicates required fields

Registration and Fees:*

$300.00 - WHEA MEMBER

Name*

First Last

Title*

Email*

Organization*

WHEA Chapter*

If you have actually paid dues to a Chapter, please pick which chapter here. If you have not, pick "Not a WHEA Member"

Address*

Street Address City State Zip

Work Phone*

See the phone format needed. Do not put a "1" before your phone number.

Representation*

Please identify the type of facility or industry and field you represent:

Please Specify Other:*

Payment Option*

Please provide P.O. Number:*

Gift Certificate #

Comments

Indicate special needs that you might want us to know about. ( i.e handicap access, Food Allergies, etc)

Total

If payment is to be made by Check or P.O. number, return a copy of your invoice page with check payable to WHEA and mail to:

Wisconsin Healthcare Engineering Association
PO Box 2254
Oshkosh WI 54903

info@whea.com

Credit Card

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Note: See registration flyer for further information on cancellation rules and cancellation fees. All registration fees must be paid in advance.