Spring Conference

REGISTRANT INFORMATION

Registrant Name

First Last

Please Choose One*

MD
DO
NP
Not Applicable

Are you an AAFP Fellow?*

Yes
No

Clinic

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Phone

Fax*

If you don't have a fax, enter all 0s

Cell*

(For MAFP use only)

E-mail*

Are you staying at the Hilton Jackson?*

Yes
No

Spouse/Guest Name

Spouse E-mail

REGISTRATION FEES

Registration*

MAFP Member - $300.00
Non-Member - $400.00
FM Resident/Student Member - Complimentary

ACTIVITIES

Catfish Dinner at MAFP

A catfish dinner will take place at the MAFP headquarters in Ridgeland.

Price: $ 15.00 Quantity:

Number Attending MAFP Dine Around Dinner Saturday Night*

MAFP makes reservations under the name MAFP and each attendee pays for their own meal. If not attending, please indicate "0."

Price: $ 0.00 Quantity:

Saturday Night Dine Around Restaurant Choice

We will place you in the reservation for the restaurant you indicate below.

Dragos
Biaggi's

Hard Copy of Conference Syllabus

Price: $ 100.00 Quantity:

Payment

CANCELLATION POLICY: Payment is due April 9. Refunds will be made upon written request to the MAFP office, minus a $50 administrative fee, if received by April 9. After April 9, no refunds will be granted.

Payment Choice*

Check (mailed to MAFP)
Credit Card

If paying by credit card, please call the MAFP after submitting this form (using the number on the screen after submitting) to give us your credit card. We are not able to accept credit card numbers online or by e-mail.

Total

$ 0.00

Name

This field is for validation purposes and should be left unchanged.