Make Check Payable To:
HEALTH AGENCIES OF THE WEST, INC.
Attorney Name: ______________________________________________
Firm Name: ______________________________________________
Address: ________________________________________________
City: ________________________ State: _________ Zip:
_________
Daytime Phone: (___) ___________ Fax: (___) ___________
E-mail: ______________________________________
# of Attorneys at $98: ____________ # of Staff at $49:
___________
(List individuals on a separate sheet and attach to registration form.)
Total Payment Enclosed: $____________________
HEALTH AGENCIES OF
THE WEST, INC.