MEMBERSHIP / SEMINAR REGISTRATION FORM Name: Address: City: ________________________ State: ______ Zip Code:_________

1. MEMBERSHIP / SEMINAR REGISTRATION FORM Name: Address: City: ________________________ State: ______ Zip Code:_______________ Phone (______)___________________________________________________ Email Address: Hospital Affiliation: Birthday( month/year)_______________ TX License #___________________ The Philippine Nurses Association of Metropolitan Houston A Closer Look into Women’s Health ☐Current Member☐ New Member☐ Renewal Membership FeeRegistration fee For Seminar ☐$80.00/ 1 year ☐PNAMH Member: $20.00 ☐ $150 .00/2 years ☐Non- member: $ 40.00 ☐$25.00 Undergraduate ☐Student: $10.00 Nursing Student for 1 year Make check payable to: PNAMH Mail to : 2702 Rocky Springs Drive, Pearland, TX 77584 Website payment: www.pnamh.com Registration Deadline: April 21, 2012 Cancellation and Refund Policy: The registration fee will be refunded (less $10.00 administrative fee) upon written notice, on or before April 25, 2012. No refunds will be granted thereafter and no telephone cancellations will be accepted. Breakfast and lunch provided; raffle and door prizes. Contact persons: Rosnela Hardesty....281.240.4705 Charmaine Shields…..832.643.7060 Aleza Espinosa……….713.269.2943 Luz Reyes………………..713.269.9380 Sponsor: The Methodist Hospital (5.25 Contact Hours) Saturday, April 28, 2012 0800 - 1355 Rio Grande Conference Room The Methodist Hospital Houston, TX 77030