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Wyoming Association of Physician Assistants
2010 CME Registration Application
Name: _______________________________________________________
Title: PA ___ MD ___ DO ___ RN ___ NP ___ Other __________________
WAPA Member? Yes ___ No ___
Address: _____________________________________________________
City: ________________________ State: _____________ Zip: _________
Email: _______________________________________________________
Social Security / AAPA / NCCPA # __________________________________ (Please list only one for CME purposes)
* Fee's include the BBQ and Banquet for Registrants. The Banquet is $35 / BBQ is $15 for guests.
(name)__________________________________________________________________
__ WAPA Banquet		How Many? ____
__ Bar-B-Que		How Many? ____
Fees	Postmarked by 6/15/2010		Postmarked after 6/15/2010	Amount Enclosed
WAPA Member	$275.00		$325.00	_____________
Non-Member PA	$360.00		$410.00	_____________
Guest (No CME credits)	$75.00		$75.00	_____________
PA Student (Program:___________)	$50.00		$50.00	_____________
Guest for WAPA Banquet	$35.00/BBQ $15		$35.00/BBQ $15	_____________
Tax ID# 830266205			Total	$____________
Make checks payable to WAPA
Mail payment to: Attn: JoAnn Ramsey, PA-C, WAPA 2010 CME,6600 East Second Street, Casper WY 82609.
Visa and or Master Card Only Credit Card : Type-________________  Card # ___________________________________ Exp.Date_________
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