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| Name: * | ||||||||||
| Designation (CPP, FPC, CPA, etc.): | ||||||||||
| Title: * | ||||||||||
| Company: * | ||||||||||
| Street Address: * | ||||||||||
| City & State: * | ||||||||||
| Zip Code: * | ||||||||||
| Phone Number: * | ||||||||||
| Fax Number: | ||||||||||
| Email Address: * |
If you do not have an email address, enter the word "none" |
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| Do you need special accommodations? If yes, please describe. | ||||||||||
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| Please indicate which Topic from
Session 1 you plan on attending.
1:45 - 3:00 pm |
Session 1 Topics (choose one)
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| Please indicate which Topic from
Session 2 you plan on attending.
3:15 - 4:30 pm |
Session 2 Topics (choose one)
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| What is your affiliation? (choose one) |
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| Luncheon Meal Choices (choose one) |
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| Are you planning to attend the Evening Social / Networking Event? |
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* Required Field
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Registration Fee and Payment |
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Fee
Amount:
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Make
check payable to: Northstar Chapter Registration Fee Due September 24 |
Mail
your check to: Medica Attn: Gloria Hoffman, CPP MR 80175 5601 Smetana Drive Minnetonka MN 55343 |
Please wait for 5-15 seconds after clicking the button above to allow time for your online registration to be processed. Thank you!
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