Name:
Profession:
Company:
Mailing Address:
City: State: Zip:
Bus. Ph: Fax: Email:


 [ ] Individual        ($50.00)

 [ ] Firm / Office    ($135.00)    Includes 3 members, additional members at individual rate.

Firm Members1

Name & Profession Phone Fax Email
       
       
       
       
       
       

Do you wish to be listed in the PWC Directory?    [ ] Yes    [ ] No

 

Please return this form with payment to:

Professionals in Workers' Compensation

P.O. Box 4435

Federal Way, WA 98063-4435

Questions, please contact PWC via email at ruffs118@msn.com

1 Firm members may send another person in their place to any program or event.