Individual Registration

Please enter information in the form below to process registration for event WIPSCOM 2023 Attendee Registration.

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Title  *

Name and Email of person completing this registration  *

Address  *

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State  *

Zip  *

Phone  *

Email of Registrant  *

Registration Information  *

I am not a member but would love more information

APCO/ NENA Member (Receive a $25 discount with # - applied @ checkout

APCO / NENA Membership #  *

Pre-Conference Course Registration  *

Price ($150)

Not attending

Will you be attending the banquet  *

Yes

No

Can we recognize you for either of these?

ENP

RPL

Conference Registration

Monday Only ($150)

Tuesday Only ($150)

Full Conference ($350)

Special Dietary Requests  *

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Special Diet Request

Payment Information

Amount

$

Payment processing fee

$

Gross amount

$

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Expiration Date*

01 02 03 04 05 06 07 08 09 10 11 12 / 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033

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