Printable Registration Form. - The American Health Lawyers

Dispute Resolution Service
Health Care Arbitration • The Westin New Orleans Canal Place • New Orleans, LA • April 22-23, 2015
Four Ways to Register:
1. Call (202) 833-1100, press prompt #2 for the Membership Service Center and have your credit card number available. 2. Fax completed registration form to:
(202) 775-2482 Attn: Dispute Resolution Service. 3. Go online 4. Mail this form with a check made payable to AHLA to American
Health Lawyers Association, 1620 Eye Street, NW, 6th Floor, Washington, DC 20006-4010.
*To avoid duplicate charges, please do not mail this form if you have already faxed it to us.
Name:________________________________________________ AHLA Member ID# (If applicable): _________________________________________
First Name for Badge (if different than above): ________________________________________Title: _________________________________________
Organization: _____________________________________________________________________________________________________________
Address: ________________________________________________________________________________________________________________
City: __________________________________________________________ State: ___________________________ Zip: ______________________
E-mail: _____________________________________________________________________ £ This is new address information; please update my file.
Telephone: (___________) ________________________________________ Fax: (___________) __________________________________________
£ This is new address information; please update my file.
Registration Fees: (Please note that registrations cannot be processed unless accompanied by payment—Hotel not included)
Please Mark Appropriate box below:
£ $785 AHLA Members £ $925 Non-member £ $685 Government/Non-Profit Member £ $825 Government/Non-Profit Non-member £ $685 Solo Practitioner Members
£ $825 Solo Practitioner Non-member
Total: $___________
Bill My Credit Card: (Check One)
£ MasterCard
£ American Express
£ Diners Club
£ Discover
Card Number: __________________________________________________________Exp. Date: ___________________________________________
Name of Cardholder: __________________________________________ Signature of Cardholder: ___________________________________________
Zip Code of Cardholder’s Billing Address: __________________ Security Code: _________________
£ Paying by Check: (Check enclosed–please make check payable to AHLA)
If you are not a member, but join when you register for the training program you will be eligible for the member registration fee! If you are interested in getting
information about membership, please contact AHLA’s Membership Service Center at (202) 833-1100, prompt #2.
Cancellations/Substitutions: Cancellations must be received in writing no later than Wednesday, April 1, 2015. Registration fees, less an administrative
fee of $125 will be refunded following the program. If you wish to send a substitute, please call AHLA’s Membership Service Center at (202) 833-1100, press
prompt #2, and please note that registration fees are based on the membership status of the individual who actually attends the program.
Please note: AHLA will charge your credit card for the correct amount if your total is incorrect. 501(C)(3) FED ID No. 23-733338