2019 April Education Event - Suppliers

Please register for the MPI CRV 2019 April Education Event occurring on April 30, 2019 by completing the form below. If you have any questions, contact MPI CRV at (860) 255-4821 or mpicrv@gmail.com.

 

(* Denotes Required Fields)

Personal Information

First Name: *
Last Name: *
First Name for Badge:
Designation (if applicable):
Job Title: *
Company: *
Address: *
City: *
State: *
Zip Code: *
Phone: *
Fax:
Email: *
Membership: *
Membership ID Number: *
Primary Chapter: *
Pursuant to the American with Disabilites Act, do you require specific aid or services?
Special Needs:

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:
Supplier Level 1 Member Quantity: Cost: $219.00
Supplier Level 1 Non-Member Quantity: Cost: $319.00
Supplier Level 2 Member Quantity: Cost: $319.00
Supplier Level 2 Non-Member Quantity: Cost: $419.00
Supplier Level 3 Member Quantity: Cost: $419.00
Supplier Level 3 Non-Member Quantity: Cost: $519.00
Additional Supplier Registration Member Quantity: Cost: $119.00
Additional Supplier Registration Non-Member Quantity: Cost: $219.00
Electric Needed *  
Mandatory Raffle Item Description *
Payment Method: *  
Interested in receiving future Sponsorship Information? *  
Discount/Sponsor Code

Payment and Cancellation Policy

  • All cancellations must occur by 5:00 pm on 4.23.19 for full refund; no refunds after 4.23.19
  • 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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