Logan Spring Symposium Registration Form

Spring Symposium
May 3-6, 2018

Required fields are denoted by a red asterisk ( * ).

Includes:

Your Information

Prefix

First Name*

Last Name*

Suffix

Maiden Name (if applicable)

State(s) of Licensure & No.(s)

State*

License #*

State*

License #*

Address

Street:

City:

State

Zip

Phone Number(s) & Email

Email Address*

Phone*

Registrations

Symposium Registration Fee: $99

Registration of $ 99 includes both social events for registrant.

Payment:

Pay by phone with your credit card by calling (800) 842-3234 or (636) 227-2100, Ext. 1960
Or pay online via the secure PayEezy site.
Or mail check (payable to Logan University) to: Logan University Alumni & Friends House 1851 Schoettler Road, Chesterfield, MO 63017

Guest cost for social events is as follows:
(choose number of guests attending with you)

Purser Center Social Event

x $20 = $0

Mix & Mingle in the Exhibitor Area

x $20 = $0

Total Cost:

If a refund is requested, the cancellation fee is $25 per registrant.
(Allow 2 weeks after Symposium for refund.)