MMCA Online Conference and Membership Registration Form

MMCA Online Conference and Membership Registration Form

Please complete the form below with as much detail as possible. A printed invoice will be delivered to the address provided. Details on combined registrations may be elaborated in the "Notes" box. If Fields marked with the red asterisk (*) are omitted, your application will not be processed. The information provided on this form will be emailed to the MMCA treasurer using the default email of the computer you are viewing this on. If you wish to be contacted at another email, please list it in the field provided.

If you wish to to send payment with your registration or would like to use a paper form and conventional mail, a pdf document is available on the "Joining" page that can be printed and mailed. Thank you for your interest in the Michigan Mosquito Control Association.

Two Day Registration.........................$75 QTY

First Day Registration .......................$60 QTY

Second Day Registration...................$40 QTY

Student Two Day................................$45 QTY

Student One Day................................$30 QTY

Exhibitor Registration........................$150 QTY

Additional Exhibit Space...................$50 QTY

Extra Dinner Ticket.............................$25 QTY

Membership Without Conference...$15 QTY

Total Amt. Due -

Name*

Company

Address *

Address

City*

State*

Zip*

Telephone*

FAX

Notes

Questions or concerns about this form may be directed to the Michigan Mosquito Control Association at the addresses listed on our home page.

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