Registration Form

MOP= H 2010 Convention

May 14 & 15, 2010

Important Dates to Remember:

· March 22, 1020 – Convention Chapter Book Submissions and Payment deadline.

· April 14, 2010 – Hotel room block reserv= ation deadline. Rooms may still be available after this date but

= &nb= sp; = not at the MOPH conference rate.

· April 14, 2010 – Catered lunch sign-up a= nd payment due.

· April 14, 2010 – Date on which the early registration discounts will end.

Personal Information: Each attendee must complete the registration form and submit with payment.

&nbs= p; &= nbsp; Name (please print)

&= nbsp; Chapter (please print)

&= nbsp; Street (please print)

&= nbsp; City &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; State &= nbsp; &nbs= p; Zip

&= nbsp; E-mail address = &nb= sp; = &nb= sp; = &nb= sp; = Phone w/area code

Lunch Preferences:<= /span>

___ Dietary restrictions/request (including vegetarian meals) must be submitted by the April 14, 2010 deadline. I have the following dietary restrictions: &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p;

Registration Fees and Event Costs:

All attendees must register and pay the registration fee.

R= egistration Fees:

Early Registration (before April 14, 20= 10)	$10.00
Registration (after April 14, 2010 or at the door)	$15.00

Catered Lunch=

Catered Lunch cost per person

$1= 0.00

Convention Chapter Book

Convention Book Business Card

$25.00

½ page layout

$50.00

Full Page layout

$100.00

        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;

    =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;    Total Registration and Lunch Fees $_________

            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =          <= /b>

            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =                  =    Total Convention Book Fees $_________

Payment Information:

<= /span>

Check enclosed for $_______

Plea= se make checks payable to MOPH Chapter 125 and send payment to:<= /b>

<= o:p>

Andy Day, JVC

Chapter 125 Convention Chairman

4068 Marseille D= rive=

St. Louis= , MO 63129<= b>=

Convention Book Business Card	$25.00
½ page layout	$50.00
Full Page layout	$100.00