WCRI | Conferences Registration

WCRI Conferences & Seminars

Workers Compensation Research Institute
Annual Issues & Research Conference
November 10-11, 2004 ~ Cambridge, Massachusetts

REGISTRATION FORM

To register, please complete this form and hit Submit at the bottom of the form. Confirmation of your registration will be sent by email. For more information, contact us by: phone: 617/ 661-WCRI (9274); fax: 617/ 661-9284; or email: conference@wcrinet.org.

Name

Name Preferred on Badge

Spouse's Name, if Attending

Title

Organization

Address

City

State

Zip

Work Phone

Phone Ext.

Email Address

Fees [Check One]	Registered By 9/24/04	Registered After 9/24/04
WCRI Member:	$550	$650
Non-member:	$700	$800
Spouse:	$75	$75

Please charge my	Visa
	MasterCard
	Amex
Name as it appears on the card
Card no.
Billing address for charge card (the address to which your credit card bill is sent)
Expiration date

955 Massachusetts Avenue Cambridge, Massachusetts 02139 617-661-WCRI (9274)