Spring 2012 Conference Registration

IMPORTANT: To be included in the conference attendee list, your registration must be received online or postmarked by February 24, 2012. (Exhibitors have a separate registration form.)

Please note that we only accept Visa, MasterCard and Discover credit cards.
* Full Name:
* Name (To Appear on your Name Badge):
* Title:
Membership Type (If Applicable):	New Member 1st Time Conference Attendee Nominee CMPE FACMPE
If you are a first time attendee, who invited you to this meeting?
Specialty Designation:
* Organization:
* Street Address:
* City, State, ZIP Code:
* Phone Number:
FAX Number:
* Email address:
* I will be attending dinner on Monday evening:	Yes No
Guest name(s) (please list) to the right:
* Items required to submit form

Your form submission WILL be encrypted using SSL to ensure your privacy.

Change of status or address? Questions about registration?
Please contact Jody O’Neil by e-mail at vmgma@comcast.net or by phone at (804) 328-3344.

A SPECIAL NOTE TO PEOPLE WITH DISABILITIES:
VMGMA wishes to take the steps that are required to ensure that no individual with a disability is excluded, denied services, segregated or otherwise treated differently than other individuals because of the absence of auxiliary aids or service. If you need any of the auxiliary aids or services identified with the Americans with Disabilities Act, please call the VMGMA Office at (804) 328-3344, prior to your arrival.