Please Print Or Type All Information. Complete One Form for Each Registrant

Registration Form

MoSTRA 30th Annual Meeting

Springfield, MO

September 21-23, 2005

Please print or type all information. Complete one form for each registrant.

**Registration due by August 30, 2005**

Name:

Credentials: Phone:

Institution:

Mailing Address:

The Registration for all three days includes Wednesday lunch, Thursday lunch and evening at Dixie Stampede (transportation included)

Annual Meeting – Total 3 days

I do plan to attend the Dixie Stampede Event

Member # $125.00

Non-member $150.00

** $25 late fee will be charged for registrations received after September 7, 2005

Additional meal tickets will be available as follows:

Wednesday lunch @ $16.95 each

Thursday lunch @ $11.95 each

Dixie Stampede @ $55.00 each

Please note any special dietary needs:

Total payment enclosed:

Please make all checks payable to MoSTRA and mail payment along with this form to:

Sheri Goodwin, RHIT, CTR

Hannibal Regional Hospital

Cancer Registry

P O Box 551

Hannibal MO 63401