Text Box: Registration Form REGISTRATION DEADLINE IS SEPTEMBER 2, 2008 Please print as nametag information will be obtained from this registration form. Name Home Address City, State, Zip Home Ph. Work Ph. E-mail Address Title/Degree Employer’s Name You will receive a course confirmation by e-mail or postcard when payment is received. This will serve as your receipt. Bring your confirmation to the conference to avoid discrepancies. Are you a SGNA/MSGNA member? Yes No *Member Number $125.00 ~ SGNA/MSGNA Members ($40 has been supplemented by MSGNA) $165.00 ~ Non-Members *If your SGNA/MSGNA membership number is not included, your registration will not be processed and will be returned to you for the non-membership fee. Please make all checks payable in United States funds to: MSGNA Please print this registration form and send it, along with your full payment, to: MSGNA Attn: Sharron Muccioli RN, CGRN 17325 Edwards Southfield, MI 48075 NOTE: All return checks are subject to a $25 return fee.