PSR Pre-Registration Data Entry

Please RSVP by Mar. 17, 2019.

Each attendee may register a guest if desired.


Patron - $85 per person		Student - $50 per person		Hosp. Pharm. Resident - $60
	Note that above early bird prices will increase after Mar. 17, 2019.

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		Bacon Wrapped Striploin
Gremolata crusted Sea Bass		Vegetarian Dish

Guest Name			(If applicable - Fee will be adjusted.)
Please select one from the menu choices below (if applicable).
Chicken, Prosciutto Gorgonzola Cordon Bleu		Bacon Wrapped Striploin
Gremolata crusted Sea Bass		Vegetarian Dish

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 "Friend of Pharmacy," please check the box and select the quantity below.
Friend of Pharmacy x		Quantity at $50 each (names listed in program)
Friend Comments (Optional)
(Please separate each individual Friend & Comment with a semicolon.)
Examples of "Friends of Pharmacy" messages could be: Congratulate honoree or Recognize a colleague or mentor.
Additional Friend sponsorship questions or comments may be submitted to Chip at psrochester@ymail.com

	Credit card payments will be accepted on PayPal after continuing.

(Please pay online in advance.)