MPA Event Registration

MSHP Annual Meeting
Radisson Hotel, Lansing. Register by Oct. 27.

First Name	*
Last Name	*
Nick Name
Member ID
Employment	*
Title
Mailing Address	*
City	*
State	*
Zip	*
Day time Phone	*
Fax	*
Email	*

Registered Member

Non Member

Fields Marked with an *asterisk are required.

Registration     Member Cost   Non Member Cost MSHP/MPA Pharmacist Member $ 50.00 $ 75.00 Pharmacy Technician Member $ 25.00 $ 35.00 Resident Pharmacist complimentary (* Residents may attend free of charge if the registration form is received by Oct. 27, postmark or fax date. Registrations received after this date will be subject to a $25 fee) $ 0 $ 0 Student Pharmacist complimentary (* Pharmacy students may attend free of charge if the registration form is received by Oct. 27, postmark or fax date. Registrations received after this date will be subject to a $10 fee.) $ 0 $ 0 Residency Breakfast complimentary $ 0 $ 0

Volunteering     I am willing to serve as a monitor for this meeting. I am willing to serve as a moderator for this meeting.