2019 Annual Gala

(* Denotes Required Fields)

Personal Information

First Name *
Last Name *
First Name for Badge *
Designation (if applicable)
Job Title *
Company: *
Street Address *
City *
State *
Zip Code *
Phone *
Email *
Are you a Member? *  
If yes, Membership ID Number
Membership/Non-Membership Type *
Primary Chapter
Pursuant to the American with Disabilites Act, do you require specific aid or services? *
Special Needs
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
Interested in receiving future Sponsorship Information? 

Photo Release

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

Payment Method *  
Sponsor/Discount Code
Please select registration type and quantity
Member Quantity: Cost: $60.00
Non Member Quantity: Cost: $70.00
Past President Quantity: Cost: $45.00
Student Quantity: Cost: $45.00

Credit Card Payment Information

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