Register Secure On-line

Please complete all information below, then click Submit to transmit your registration electronically to the APTA/Colorado Chapter. A confirmation page will appear if your registration was transmitted successfully. If not, it may be necessary to re-submit your registration via fax to 303-694-4869.

A confirmation notice will be emailed to all registered practices on Monday, January 15th.

Registration fees are based per-dial-in connection; multiple dial-ins from your practice will be charged. We are unable to accommodate more than one practice or department per call-in. 

Written requests for refunds received on or before Wednesday, January 10, 2007, will receive a 50% refund, less a $50 processing fee; fees are nonrefundable after this date. There are no refunds for no shows.

Practice/Facility Name

Contact person

Address

City, State, Zip code

Phone

Fax

Email*
                   *Your confirmation will be sent via email.

Number of participants expected to attend from your practice

Registration Fee
The fee includes one dial-in connection. Additional fees will be charged if there are multiple dial-ins.

$149 for Practices with 4 or more PTs on staff

$129 for Practices with 2-3 PTs on staff

$109 for Practices with only one PT on staff

Payment

VISA

MasterCard

American Express

Check payable to APTA/Colorado Chapter 
      Your check is due within 5 business days of online registration.

Purchase Order include reference number

Cardholder name

Card number include dashes

Expiration date

If paying by credit card, a receipt will be mailed to the contact person and address listed above.

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