DIVISION 55 FOURTH ANNUAL MID-WINTER CONFERENCE

NATIONAL UNITY FOR RxP

PUTTING IT ALL TOGETHER FOR MISSOURI AND BEYOND IN 2008

January 9th – 12th, 2008

Register online with the following link to the

Missouri Psychological Association

Or Print out an Mail in the Following

REGISTRATION FORM

Registration fee for Jefferson City: $25 ______

Registration fees for Kansas City:

Division 55 or Division 18 member: $350 _____

Non-member: $375 _____

Student rate: $175 ______

Division 55 NEW membership fee only $10 __ with registration fee of $350 _______

Nelson-Atkins Museum Dinner ONLY: $75 ______

Payment Method: Check ____ Mastercard _____ Visa ______ Total payment: ________

Credit Card # ___________________________________________ Expiration Date: _______

Name ______________________________________________________

Organization _________________________________________________________________

City _________________________________________ State ____________ Zip __________

Phone: (_____)_________________________ E-mail _______________________________

Make check payable to: Forest Institute

Cancellation deadline: December 10, 2007 (no refunds after this date)