Registration

Please use the form below to sign-up and pay for registration.

Hotel Info

Embassy Suites
1040 P St
Lincoln, NE 68508

Wednesday October 10^th, 2021 will be the last day to cancel your registration for a full refund. Cancellation requests after this date are subject to review by the Nebraska Symposium committee. If you need to cancel your registration, please click here and provide your information with written notice of cancellation.

2021 Nebraska Symposium Registration

First Name *

Last Name *

Company *

Job Title *

Credentials for Submitting CEUs

Nursing

PT/PTA

ATC

Attorney

CCM

OtherOther

None

Nursing License Number *

PT/PTA License Number *

AT/BOC License Number *

Attorney License Number *

CCM Number *

Address *

Address

Address

Address

City

City

State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

State/Province

Zip/Postal

Zip/Postal

Email Address *

Select Early Registration * NE Symposium - $150.00 Vendor Registration - $0.00 Presenter Registration - $0.00 NE Symposium Board/Committee Member Registration - $0.00 Sponsor - $0.00

Select Regular Registration * NE Symposium - $200.00 Vendor Registration - $0.00 Presenter Registration - $0.00 NE Symposium Board/Committee Member Registration - $0.00 Sponsor - $0.00

Payment Method * Credit Card Check

Please mail checks to:

PO Box 24054
Omaha, NE 68124

Make checks payable to “Workers' Compensation Association of Nebraska”

Credit Card Holder First Name *

Credit Card Holder Last Name *

Cardholder Address *

Cardholder Address

Cardholder Address

Cardholder Address

City

City

State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

State/Province

Zip/Postal

Zip/Postal

Credit Card *

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