Leadership Day On Capitol Hill Registration Form
May 15-16, 2007
Wyndham Washington, D.C. Hotel
(soon to be Westin Washington, DC City Center)

IMPORTANT: Please submit your list of attendees no later than Friday, April 27 for your chapter’s attendees to receive briefing materials in advance of Leadership Day. Please indicate whether you and/or your delegate(s) plan to attend the Key Contact Awards Dinner on Tuesday, May 15 at 7 PM as well as the optional pre-course that morning from 8:45 AM - 12:15 PM. Because of the cost of the dinner, it is especially important to get an exact meal count. To register multiple attendees, complete and submit this form, then click the “add next registrant” button on the thank you page. If you have any questions about registering for Leadership Day, contact Shuan Tomlinson stomlinson@acponline.org. If you would like to forward this form to another potential Leadership Day attendee, click here .

Note: Fields marked with * are required.

ACP chapter*:            
Submitted by*:
Attendee Information
First Name*:
Middle Name or Initial:
Last Name*:
Suffix: (e.g. MD, DO)
Member Status*:
Address 1*:
Address 2:
Address 3:
City*:
State*:
Zip/Postal Code*:
Phone*:      
Fax:
E-mail:

Please indicate if you plan to attend the Student and Associate Briefing on Monday, May 14, 4:00 - 6:00 PM:
Yes   No

Please indicate if you plan to attend the Pre-course on Tuesday, May 15, 8:45 AM - 12:15 PM:
Yes   No

Please indicate if you plan to attend the ACP Services PAC Reception on Tuesday, May 15 at 6:00 PM (must be a PAC member in 2007 to attend; to become a member, click here):
Yes   No

Please indicate if you plan to attend the Key Contact Awards Dinner on Tuesday, May 15 at 7:00 PM and your meal preference:*
Yes  No

Meal Preference
Beef Tenderloin Vegetarian Kosher


HOTEL LODGING
Wyndham Washington, D.C. Hotel
(soon to be Westin Washington, DC City Center)
1400 M Street, NW (M & 14th Streets, NW)
Washington, DC 20005-2750
Fill out the Reservation Form and FAX to (202) 785-0786 Attn: Reservations.
A limited number of hotel rooms are available at the Wyndham Washington, D.C. Hotel so make your reservations as soon as possible. Room requests and rates cannot be guaranteed after April 23.