XSITE Registration - Education and Luncheon ONLY

Please register for our MPI CRV New England Business Forum, Powered by XSITE, by completing the form below. If you have any questions, contact Allyson J. Deckman at (860) 541-6438 or mpicrv@gmail.com.

XSITE REGISTRATION (EDUCATION SESSIONS AND LUNCHEON ONLY)

(* 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: *
Primary Chapter: *
Pursuant to the American with Disabilites Act, do you require specific aid or services?
Special Needs:
Do you know of anyone that would be interested in learning more about MPI CRV?

Guest Information

EFFECTIVE JULY 1, 2016: Anyone who is not a preferred or premier level member is required to pay the non-chapter member rates for events and is limited to no more than 2 events in one fiscal year at the non-chapter member rate.
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:

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:
MPI Members (Preferred/Premier Level) Quantity: Cost: $75.00
Non-Members & MPI Essential Level Members Quantity: Cost: $85.00
MPI Student Members Quantity: Cost: $45.00
MPI CRV Past President Quantity: Cost: $45.00
Payment Method: *  
  • Send check or money order to:
    MPI CRV, Attn: Allyson J. Deckman
    701 Hebron Avenue - Third Floor, Glastonbury, CT 06033
  • Confirmation of your registration will be sent via email.

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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