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Earlv Refristration GOVT 178925 2006 Minnesota Municipal Clerks Institute (MMCI) Name: S(~2.e-eVley 6r/~ It" Last . First City of C-t vJ ~ev I j I L Population~ . Department:. --B ~ lOrA.. Yl. +, ~ ~ ... Position Title: III ~ oo...YL+ . ej~ /L.IL "]:I:: Address: /81(0 fYJlt{ ~ . S./1.a+ City, State, Postal Code: Cf",../e,ru:ILt M1.tf) ~~.. YEAR THREE Work Telephone: Ie )/-~ ze;, S2-~ E-mail address:h~ ~vl!.. (l~ ~ytJiJ '/"'/:;: ;"~~signate a year Soci~1 Security No. I D7 7, '. (Last 4 digits only). '. '. ~Iease do not list my email address on the public list (please check). Scholarship and Payment Information for 2006 MMCI: Ii\.. Please Enroll me in the 2006 MMCI for: Mol. ~7DO ~EAA ONE ~ YEAR TWO Before May 16: MCFOA member: $410 After May 16: MCFOA member: $430 Non-MCFOA Member: $450 /-"---..~.........-....\ (_ I plan to attend the \ \ banquet on Thursday j . . .....................--...~-~."..._.._-~/ Non-MCFOA Member: $470 V I am applying for an MCFOA scholarship. I understand you will bill me in May and that payment is due before the conference. I wish to secure a place at the Institute and enclose payment in the amount of $ [Check or money order is payable to University of Minnesota. A $20 service charge will be applied if returned for insuf- ficient funds, closed account, or Stop Payment request.] . Lplease bill my employer. reference Purchase Order no. Please charge my credit card in the amount of $ - Visa _ MasterCard _ Discover _ American Express Card Nu-mber: Expiration Date: Name as Printed on Card: Signature of Cardholder: Mail registration and payment to: GOVT 178925 University of Minnesota 20 Coffey Hall 1420 Eckles Avenue Saint Paul MN 55108-6069 Lodging and Conference at Americlnn Hotel & Suites - Mounds View,. 763-786-2000 or 1-800-634-3444 Reservations guaranteed until June 27th. Mention you are attend.ing MMCI to get special Institute room rate of $69.90/night + 9.5% tax. The information on this fonn is private data, used to identify and locate you, obtain payment, and enable instnlctors to better know their audience. Name, address, and payment method are mandatory. Jfyou desire CEU certification and do not supply a Social Security number, an' alternative identifier will be used. Information on this form, except Social Security number, may be shared with instructors and program cosponsors. Cancella- tions are subject to a $30 service charge. Registrants who fail to attend or who cancel seven days from the start of the program are responsible for tile entire fie. You must notify the registration office in writing o/your cancellation. /f!