A component of AHDI - Association for Healthcare Documentation Integrity
Prairie Rose Chapter - North Dakota
Contact:  Dawn Beardemphl, Treasurer
3415 20th Ave. S, #311, Grand Forks, ND 58201
(701) 780-6011     -    [email protected]
2009 Spring Symposium Registration Form
Symposium Date:      Saturday, April 4, 2009
  Symposium Time:      8:00 a.m. to 4:00 p.m.
  Symposium Place:    Comfort Inn, Bismarck, North Dakota
  Symposium Registration Fees (includes Luncheon):
   $35 - Pre-registered National AHDI Members
   $40 - Pre-registered Medical Transcription Students
   $40 - Pre-registered AHDI Nonmembers
   $45 - Registration after April 1, 2009
NAME OF ATTENDEE:   _________________________________________________

STREET ADDRESS:   ___________________________________________________

CITY:   __________________________    STATE:   ________       ZIP:   ___________

TELEPHONE NUMBER:   _______________     AHDI MEMBER NUMBER  ___________

E-MAIL ADDRESS:   ____________________________________________________

FEE PAID (CHECK ONE)  $35 ________       $40 ________        $45 _______
Complete this form and mail it
by April 1, 2009,
along with a check payable to
"Prairie Rose Chapter AHDI" to:
Dawn Beardempl, Treasurer
3415 20th Ave. S. #311, Grand Forks, ND   58201
(701) 780-6011
Address questions/comments to: dbeardemphl @altru.org
********************************************************************************
PAYMENT INFORMATION (FOR OFFICE USE ONLY)
Postmark Date:   _________________________________________
Name of Payee: _________________________________________
Check #:   ______________________________________________
Check Amount:  _________________________________________
Deposit Date:   __________________________________________
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