Registration Form

The conference begins on Sunday, March 2 at 6:30 p.m. with a resource fair and adjourns on Wednesday, March 5 at 12:00 p.m. The registration fee covers three continental breakfasts, 2 luncheons, heavy hors d'oeuvre reception, morning and afternoon breaks, and on-site conference materials. Checks should be made payable to the SRDC (Federal ID # 64-6000819). Registration refunds will be made for cancellations made three working days prior to the conference.

Name: ____________________________________________________

 

Preferred Name: ____________________________________________________

 

Title: ____________________________________________________

 

Organization: ____________________________________________________

 

Address: ____________________________________________________

 

City: ____________________________________________________

 

State: _______________

 

Zip: _______________

 

Phone: ______________________

 

Fax: ______________________

 

E-mail: ____________________________________________________
   
Registration Information:

Early Registration: February 10--$200 __________

Final Registration: February 26--$250  __________
 
Payment Information:
________
 Check q enclosed q to follow
________
 Purchase order q enclosed q to follow
________
 Money order q enclosed q to follow
________
 Credit Card (see below)
 
Credit Card Type ____________________________________________________________________
 
Credit Card Number __________________________________________________________________
 
Name of Card Holder _________________________________________________________________
 
Expiration Date ______________________________________________________________________
 
Signature __________________________________________________________________________

 

Return to:
Southern Rural Development Center
Box 9656 n 410 Bost Extension Building
Mississippi State, MS 39762
Phone: (662) 325-3207 n Fax: (662) 325-8915
bonniet@srdc.msstate.edu
http://srdc.msstate.edu