Nevada Occupational Therapy Association
Conference Registration Form

 September 19^th, 2008: Meet & Greet with AOTA President Penelope Moyers Cleveland

Three Tomatoes & A Mozzarella, 6pm - Limited engagement, first come/first serve basis, includes dinner, soda/water, and dessert

OT/COTA $35 _____

Student $25 ____

September 20^th, 2008: Conference

            The Orleans Hotel & Casino, 7:30am- 6pm

NOTA (or other state association) Member OT Conference Fee $125 _________

NOTA (or other state association) Member COTA Conference Fee $115 _________

*Option to sign-up for or renew annual NOTA membership through Oct 2009 ($5 discount with conference registration)

                                    *OT $70 ____________                     COTA $60 ____________

                        Nonmember OT Conference Fee $155 ______

                        Nonmember COTA Conference Fee $ 142.50 _______

Current OT/COTA Student $35.00  _________

*Registration form must be postmarked by September 1^st, 2008.
*Registration will be available at the door based on availability ($10 late registration fee).
*State Association Membership will be verified, please provide verification with submittal

 Name _____________________________________ Title ____________

Address ___________________________________________ City _________________ State ___ Zip ______

Phone __________________ Email ___________________________ Practice Area _____________________

Make Check Payable to NOTA PO Box 28353, Las Vegas, NV 89126-2353

Visa/MasterCard # _______________________________ Exp _______________ CRV # ________

Total Included: $ __________     Signature:___________________________________________________

Name/Billing info on CC if different from above: ______________________________________________

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