MESDA's 12th Annual Conference
Friday, November 12, 2004 DoubleTree Hotel
Registration
Registration Form
Prepayment is required.Reservations are non-refundable. A registrant may designate
a substitute attendee by calling the MESDA office. Questions? Contact Joe Kumiszcza at
MESDA (207) 829-9195
Organization:
Contact Name:
Title:
Address 1:
Address 2:
City:
State:
Zip:
Telephone:
Fax:
E-mail:
List registrants here (including
yourself, if you will be attending):
Payment Information:
Conference registration Fees: MESDA Members $99.00; Non-Members $129.00
# of MESDA Members Attending: x $99
# of Non-Members Attending: x $129
Total amount enclosed $
Select payment method:
Account Number:
Name on Account:
Billing Address:
Expiration Date:
Card Verification number*:
*This is the 3 digit non-embossed number printed on the signature panel on the back of the card immediately following the Visa or MC card account number or the 4 digit, non-embossed number printed above your account number on the face of your American Express card.
If you prefer not to submit your credit card information over the Internet
or want to pay by check, please send the completed registration and your payment (make
checks payable to MESDA) to: MESDA, P.O. Box 10020, Portland, ME 04104-0020.
