Mississippi Petroleum Marketers and Convenience Stores Association

Endorsed Programs

Recommended Programs

Advanced Meeting Registration
Prepare separate form for each person or couple registering.
Click here for brochure and printable registration form

Name as desired
on badge:

Company:

Mailing Address:

City/State/Zip:

Brand(s) if gasoline distributor:

Phone/Fax:

Name of Spouse
(if attending):

Full Registration - MPMCSA/MWDA Members: Late registration fees will be enforced	Before June 21	After June 21	Amount
Registration Fees
Member Registration	$325.00	$375.00
Spouse Registration	$125.00	$175.00
Non-Member
Non Member Registration	$450.00	$500.00
Spouse Registration	$150.00	$200.00
Child's Registration: Entitles child to participate in Thursday and Friday functions - Under 4 - No Charge
Age 4-12	$30.00	$50.00
Age 13-17 - all functions	$50.00	$75.00
Name Age Name Age Name Age Name Age
Ticketed Functions
Spouses' Dream Therapy Workshop	$20.00	$30.00
Golf Tournament (per person)	$150.00	$175.00
Please register the following person(s) for: Golf Handicap Golf Handicap

Payment - An Additional $10.00 processing fee will be added to all Credit Card Charges.

Payment Type:

Total Due:

Credit Card #:

Expiration:

Cardholder Name:

Registrations cannot be processed without full payment, including ticketed functions. Phone registrations cannot be accepted.

Registrations cancelled in writing by June 30, 2010, will be refunded. Ticketed fees are non-refundable.

Registrations cancelled after June 30, 2010, or no-shows will not be refunded except for extreme cases.