February 9, 2012
Registration		 Fax to:
    (608) 204-9818		 Mail to:
      2830 Agriculture Dr.
      Madison, WI 53718		 ** You may need to manually set your margins to .5 inch. **
  Personal Information
Full Name:
Title/Position:
Company/Affiliation:
Address:
City: State: Zip:
Phone: Fax: Email:

Please indicate the following (check all that apply)
I am an MPI member
I’m attending my first MPI-Wisconsin Event

Needs
  If you have special dietary needs or require assistance with physical accomodations, please contact the MPI-WI chapter office at (608) 204-9816.

Registration Fees
Event
Member — $45
(* $55 late after 2/03/12 -
please Login to register)
Non-Member — $55
 
Student — $25
(* $55 late after 2/03/12)
  * Registration received after 5 p.m. on Friday, February 3, 2012 will automatically be charged the late rate.
Method of Payment
Mastercard       Visa       American Express
Credit Card Number: Exp. Date:
Three digit verification number (on back of credit card):
Name as it appears on card:
Billing Address for Credit Card:


No refund will be given for cancellations after
noon on Friday, February 3, 2012
 
 
 
MPI Wisconsin Headquarters
  ::   2830 Agriculture Dr.   ::   Madison, WI 53718   ::  
  ::   Phone: (608) 204-9816   ::   Fax: (608) 204-9818   ::   Email: admin@mpiwi.org   ::  
 
 
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