Mississippi Academy of Family Physicians
Mississippi Practices & the Medical Home
April 9-11, 2010
Eagle Ridge Conference Center
Raymond, Mississippi
General
Company/Clinic:
Address:
City:
State:
Zip:
Phone:
Fax:
Email:
Practice Size:
(by Physician FTE)
Registrants
Name:
Title:
Registrant One:
Registrant Two:
Registrant Three:
Registrant Four:
Registration Fees
MAFP Member & One Staff
$350
Non Member & One Staff
$450
Additional Registrants
$150
N/M Additional Registrants
$175
Resident Member
$125
Credit Card Information
Credit Card:
Visa
Master Card
American Express
Discover
Cardholder Name:
(Exactly as appears on credit card)
Billing Address:
Billing Zip:
Credit Card No.:
Expiration Date:
CVV Code:
(3 digit # on back of card, 4 digit # on AmEx)
Payment Amount:
$
(Enter payment amount authorized to charge to credit card)
