2018 XSITE Supplier Registration - Appointments and Education

This registration is for suppliers who wish to attend the education sessions AND take appointments at the reverse tradeshow.

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

Not a member of MPI? No problem! Non-MPI Suppliers are also welcome to register!

CLICK HERE FOR EDUCATION AND LUNCH ONLY


XSITE SUPPLIER REGISTRATION (APPOINTMENTS & EDUCATION SESSIONS)

MPI CRV will contact you regarding the status of your registration to participate in the Appointment Trade Show. If you are not approved, you will have the opportunity to register for the Education and Luncheon portion of the program.

(* 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

Supplier (Up to 15 Qualified Appointments) Quantity: Cost: $999.00
Supplier - Second Representative Quantity: Cost: $25.00
Payment Method: 
Confirmation of your registration will be sent via email.

Payment and Cancellation Policy

  • Eligibility for a refund if you cancel your MPI CRV New England Business Forum Powered by XSITE registration is based on the below timeline:
  • 61 days or more: 50% refund
  • 31 to 60 days: 25% refund
  • 30 days or less: 0% refund
  • Anyone who does not show for the event will be charged in full.
I have read and agree with the above Payment and Cancellation Policy. *  

Credit Card Payment Information

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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