Registration form

Text Box: Stars in GI Registration Form - MSGNA 2010 Spring Conference (Print clearly-information is used for your name tag) Registration form must be postmarked no later than February 27, 2010 Name Title Street Address City State ZIP Work Phone Home Phone E-mail Employer SGNA/MSGNA #____________ (Registration will be returned for additional funds if Membership # is not provided.) [ ] $75.00 SGNA/MSGNA Members [ ] $140.00 Non-Members Make all checks payable to MSGNA (United States funds) If your facility is paying for your registration, include all participants’ names on the check. You will receive a course confirmation by e-mail or postcard when payment is received in full. Bring this confirmation to the conference to avoid discrepancies. Mail registration form and payment by February 27, 2010 to: Diane Gastion 40 Davenport Apt. 702 Detroit, MI 48201