MPI CRV Chapter Event - July After 5'

Please resiger for our July After 5' Chapter Event 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 (charges apply as noted below): *  
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. *  

Donations

Would you like to make a donation to the MPI Foundation? If so, please enter the amount here: Amount: $

Payment Information

Please choose the number of registrations for each pricing category:
Member Quantity: Cost: $15.00
Non-Member Quantity: Cost: $15.00
Student Quantity: Cost: $15.00
Past President Quantity: Cost: $15.00
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 7/1 or you will be contacted to guarantee with a credit card.
  • All cancellations must occur by 5:00 pm on 7/1 for full refund; no refunds after 7/1
  • 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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