2016 June Awards Gala

Please register for the MPI CRV 2016 June Awards Gala by completing the form below. If you have any questions, contact Allyson J. Deckman at (860) 541-6438 or mpicrv@gmail.com.

 

(* Denotes Required Fields)

Guest Information

Please NOTE that non-members may only attend two (2) MPI CRV Chapter Educational meetings per fiscal year (July 1 - June 30) before joining the association.
Will you be bringing a guest (please account for guests below as charges apply as noted): *  
Guest #1 First Name:
Guest #1 Last Name:
Guest's Membership:
Guest's First Name for Badge
Guest's Company:
Guest #2 First Name:
Guest #2 Last Name:
Guest's Membership:
Guest's First Name for Badge:
Guest's Company:

Photo Release Statement

I give the MPI Connecticut River Valley Chapter, the absolute right and permission to use my photograph(s) in its promotional materials and publicity efforts. I understand that the photograph(s) may be used in a publication, print ad, direct-mail piece, electronic media (e.g. video, CD-ROM, Internet, World Wide Web), or other form of promotion for the Chapter. I release MPI CRV, the photographer, their offices, employees, agents, and designees from liability for any violation of any personal or proprietary right I may have in connection with such use.
I have read and agree with the Photo Release Statement. *  

Payment Information

Please choose the number of registrations for each pricing category:
Member Quantity: Cost: $55.00
Future Member Quantity: Cost: $65.00
Student Quantity: Cost: $40.00
Past President Quantity: Cost: $40.00
Payment Method: *  
  • Send check or money order to:
    MPI CRV, Attn: Allyson J. Deckman
    330 Main Street - Third Floor, Hartford, CT 06106
  • Confirmation of your registration will be sent via email.

Payment and Cancellation Policy

  • Check or money order must be received by 6.3.16 or you will be contacted to guarantee with a credit card.
  • All cancellations must occur by 5:00 pm on 6.3.16 for full refund; no refunds after 6.3.16
  • Anyone who does not show for the event will be charged.
I have read and agree with the above Payment and Cancellation Policy. *  

Credit Card Payment Information

(All credit card information must be filled out completely to make a payment.)
Amount:
Card Type:
Card Number:
Name on Card:
Verification #:
Expiration Date: (MM/YYYY)
Billing Address:
City   State   Zip:

Confirmation Email

Send Confirmation Email To: *


MPI CONNECTICUT RIVER VALLEY CHAPTER

701 Hebron Avenue - 3rd Floor
Glastonbury, CT 06033
Phone: 860.541.6438

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