Registration – Missouri Department of Mental Health’s Spring Training Institute 2012

• Please fill out the form below. A confirmation with further information will be sent upon receipt of your payment.

  or use this STI Printable Registration Form (right-click and choose save-as)

  The Early Registration fee of $165 for the full program and $85 for one day is in effect until April 30, 2012.

  All participants will receive an electronic version of handouts at the program. A printed version is available for $25.

  Conf:
  Price: *	$190 full program $100 Thursday only $100 Friday only   $215 full program with printed handout $125 Thursday only with printed handout $125 Friday only with printed handout
  Location*	Thursday, May 31 and Friday, June 1, 2012 at Tan-Tar-A, Osage Beach, MO
  Payment Options *	Credit Card Bill My Employer
  Name *
  Address *
  City *
  State *	Missouri Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
  Zip *
  Email Address *
  Daytime Phone *
  Profession
  Degree
  Employer *
  Work Address *
  Work City *
  Work State *	Missouri Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
  Work Zip *
  Work Phone *
  Purchase Order Number *
  Fiscal Contact’s Name
  Fiscal Contact’s Phone

  * = required fields

  * = required field only when paying by invoice

   

  If paying by credit card (Visa or MasterCard only), you will be forwarded to the University of Missouri’s QuikPay system in order to enter card information.

  If paying by invoice, we will send your conference registration upon receipt of a hard copy of your purchase order.

   

  Cancellations or Substitutions:

  If you are unable to attend, we ask that you notify us as soon as possible. Cancellations received in writing five business days prior to the date of the program will be refunded, less a $25.00 processing fee. You may send a substitute, but we ask that you notify us in writing of this change. If you do not attend or send a substitute, you or your employer will be billed the full registration fee.

   

  or use this STI Printable Registration Form (right-click and choose save-as)