REGISTRATION FORM
Wild West Veterinary Conference - October 11-15, 2017
CONTACT INFORMATION
Please print clearly and use one form per registrant
First Name Last Name
Designation(s)
Company / Practice
Address
City State Zip Country
Work Phone Alt Phone Fax
E-mail (required)
Are you licnesed in     New York     Texas
CONFERENCE RATES
Early rates are through August 1. All registrations received August 2 - October 7 will be charged the regular rates. Registrations received October 8 - 16 will be charged the onsite rate.
Early Bird:
On/Before Aug. 1
Advanced:
Aug. 2 - Oct. 7
Onsite:
Oct. 8 - Oct. 16
Veterinarian $495 $545 $595
Intern/Resident $295 $345 $395
Veterinary Technician $295 $345 $395
Practice Manager $295 $345 $395
Veterinary Student $175 $200 $225
Other Medical Professional $495 $545 $595
One Day Veterinarian, Other Medical Professional $325 $325 $325
One Day Technicain, Staff,
Intern/Resident, Practice Manager
$195 $195 $195
One Day Student $100 $100 $100
One Day (select one) Wed Thurs      Fri Sat
Spouse / Guest $175 $200 $225
Exhibit Hall Only 1-day $150    
Spouse / Guest Name(s)
 
PAYMENT INFORMATION
A Conference Badge Total:
B Laboratory Total:
C Special Event Total:
REGISRATION TOTAL:
Registration is available via mail, fax and online at wildwestvc.com
FAX: (703) 978-7025
MAIL: WWVC Registration Center
5270 Lyngate Court
Burke, VA 22015
Check enclosed, made payable to Wild West Veterinary Conference (Check #___________________)
Charge my: Visa MasterCard American Express
Card Number Exp Date
Cardholder Name
Billing Address
CityStateZipCountry
Signature
Practical Continuing Education for Veterinary Professionals | (877) 978-7084