ITA/ELIGIBLE PROVIDERS DEMONSTRATION CONFERENCE
Sheraton Dallas Brookhollow
1241 West Mockingbird Lane
Dallas, TX 74247
214-630-7000
September 27-28, 1999
REGISTRATION FORM
Please type or print the information for registrants as it is to appear on each
name badge. To receive confirmation of the registrations, a fax number must be
provided. A maximum of two registrants from each organization can attend. If
additional space is available you will be contacted.
Participant One: _____________________________________________________________
First Name: _____________________________________________________________
Last Name: _____________________________________________________________
Organization: _____________________________________________________________
Title: _____________________________________________________________
Mailing Address: _____________________________________________________________
City: __________________________ State: ____________ Zip: _________________
Telephone: _______________________ Fax: ______________________
E-mail: __________________________
Participant Two: _____________________________________________________________
First Name: _____________________________________________________________
Last Name: _____________________________________________________________
Organization: _____________________________________________________________
Title: _____________________________________________________________
Mailing Address: _____________________________________________________________
City: __________________________ State: ____________ Zip: _________________
Telephone: _______________________ Fax: ______________________
E-mail: __________________________
HOTEL RESERVATIONS
Please fax your registration to Sheritta Cooper Porter, Conference Coordinator,
at 202-638-2385 or mail to:
Research and Evaluation Associates, Inc.
ITA/Eligible Provider Conference Coordinator
Attn: Sheritta Cooper Porter
1333 H Street, NW, Suite 300 West
Washington, DC 20005
202-842-2200
A rooming list of confirmed registrants will be provided to the Sheraton Dallas
Brookhollow, in Dallas, TX. A confirmation notice will be faxed to each
registrant. After you have received confirmation of your registration, you will
need to contact the hotel to guarantee your registration. Please indicate below
the number and type of rooms you will need.
Quantity Rate
_______ Single $89 plus tax per night (Federal Government Rate)
_______ Double $89 plus tax per night (Federal Government Rate)
Check the date of the meeting you would like to attend:
----------September 27
----------September 28
