Minnesota Nursing Home Social Workers Association
Dedicated to enhancing total person care through advocacy, education, leadership, and support
MNHSWA VENDOR REGISTRATION September 29th, 2016
Organization Name: ______
Address: ______
Contact Person: ______
E-Mail: ______
Phone: ______
(Confirmation will be e-mailed if you provide an email address)
Any special accommodations you need? Electricity
Corner space for larger display
Other requests (we will try to honor these on a first come first served basis): ______
Number of conference booklets you would like to receive: ______
(Note: each book is $25.00—please include payment with conference registration)
Will you be providing a door prize? Yes No
Number of lunches you plan for on Thursday:______
(If you wish to have more than 2, please include $10.00 for each additional meal)
Name(s) of those who will be receiving CEUs:______
Total Enclosed: $150.00 + ______= ______
This completed form and payment should be sent by September 1st to:
Brandi Blais LSWSt. Cloud Carefree Assisted Living
1225 E Division St
St. Cloud MN 56304
(320) 251-6483 (work)
(320) 492-2446 (cell)
(320) 251-2714 (fax)