APPLICANT INFORMATION:

Application Date: -- Month January February March April May June July August September October November December | Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 | 2005 Last Name: First Name: Middle Initial: Preferred Mailing Address: Address: Address 2: City: State: Zip: Telephone Number: E-mail:

GUEST INFORMATION:

Pricing Information and Number of Tickets Required: $40.00 Member/Member Guest $20.00 Resident $75.00 Non-Member (*) (*) PLEASE NOTE: Non-members may join on-line by clicking HERE. Annual dues are $90. For residents, dues are waived. Thanks to generous sponsorship support, the luncheon fee for residents has been reduced. Additional resident support may be available upon request. I WILL SPONSOR the following guest(s)/resident(s). In order to secure tickets, names are required. If you are unable to provide names, the individual(s) WILL NOT be admitted without a ticket. Please print below. Make photocopy of form if submitting more than six (6) names. LIST GUESTS ATTENDING (check all events that apply) Luncheon Networking Reception WDS Open House List Guests Attending: 1. 2. 3. 4. 5. 6. Additional Guests List All: If submitting more than six guests list additional guests here Request reunion seating instead of randomly assigned seating at the Luncheon Number attending Annual Luncheon? Number attending Networking Reception on 2/18? Number attending WDS Open House on 2/20? SEATING: To encourage networking and stimulate lively conversation, attendees will be assigned randonly to tables. For those who use this event as an opportunity to catch up with specific friends and colleagues, reunion seating will be available on a limited basis. Requests will be honored, as available, at the Luncheon only.

ADDITIONAL INFORMATION:

The Women’s Dermatologic Society Foundation Contribution …a new non-profit organization dedicated to supporting the objectives and activities of the Women’s Dermatologic Society (WDS) welcomes your optional donation. Details about the WDS Foundation | Donations available Online Questions? eMail: wds@womensderm.org -or- Call: (415) 764-4925 Additional Comments or Special Request: List Comments or Request Here

Women's Dermatologic Society
575 Market Street, Suite 2125 • San Francisco, CA 94105
FAX: (415) 764-4933