THE MISSOURI PERFUSION SOCIETY
17th Annual Scientific Meeting
Kansas City, Missouri
June 8-9, 2012
REGISTRATION FORM
(Highlight form & Print to mail check payment or use Pay Pal to register on-line)
Meeting Registration Fee (s)
Pre-Registration before 5/25/2012
TMPS members: $100.00
Non-Members: $150.00
On site: $200.00
Students/Spouses Free
Your cancelled check is your receipt: Amount enclosed: _____
Name: ___________________________________
Address: _________________________________
_________________________________
Email: ___________________________________
Telephone: _______________________________
Check payable to: The Missouri Perfusion Society
c/o Kellie Merrigan, Treasurer
15406 Iron horse Circle
Leawood KS 66224