PSR Pre-Registration Data Entry

Please RSVP by Sep. 26, 2021.

Each attendee may register a guest if desired.


Patron - $90 per person		Student - $55 per person		Hosp. Pharm. Resident - $65

	Note that above early bird prices will increase after Sep. 26, 2021.

Attendee First Name		Last Name


Street Addr		City			State	Zip
Phone (123-456-7890)		E-mail
If payer name on credit card will be different from attendee, please fill in below.
Payer 1st Name		Last Name


Please select one from the menu choices below.
Chicken Prosciutto Gorgonzola Cordon Bleu		Cappuccino Crusted Roast Tenderloin of Beef
Caramelized Salmon with Lemon Caper Butter		Vegetable Lasagna Alfredo

Guest Name			(If applicable - Fee will be adjusted.)
Please select one from the menu choices below (if applicable).
Chicken Prosciutto Gorgonzola Cordon Bleu		Cappuccino Crusted Roast Tenderloin of Beef
Caramelized Salmon with Lemon Caper Butter		Vegetable Lasagna Alfredo

If you would like to sit with others, enter up to 3 names below. We may not be able to accommodate all requests.




If you would like to be a "Signature Cocktail" sponsor, please check the box and select the quantity below.
Signature Cocktail x		Quantity at $200 each (names listed in program)
Name of cocktail (Optional)
(Please separate each individual Cocktail & Comment with a semicolon.)
Additional sponsorship questions or comments may be submitted to Chip at psrochester@ymail.com

	Credit card payments will be accepted on PayPal after continuing.

	Please check the box below before hitting the continue button.

(Please pay online in advance.)