Name _________________________________________________________________

Studio _________________________________________________________________

Address ___________________________________________________________

City/State/Zip ___________________________________________________________

Work Phone ______________________ Home Phone ________________________

Name(s) to appear on badge(s) ______________________________________________

_______________________________________________________________________

Number	Description	Totals
_______	PPMA Silver Active Member Registration	n/c
_______	Seminar Registration @ $60 per PPMA/SEPPA member	$_________________
_______	Riverboat cruise (hot hors d'oeuvres, cash bar) @ $10  Reservations for Riverboat cruise must be received by 9/26	$_________________
	TOTAL AMOUNT	$_________________

Hotel reservations must be made by 9/23 for PPMA rate of $109.
Embassy Suites, phone 334-269-5055, code "PPMA"

Paid by Check # __________

Paid by VISA/MC: Account # ______________________________________________

Expiration Date ________________ Signature ________________________________

Name on Credit Card (please print) __________________________________________
 

Send registration with payment to:

Buddy Thompson, secretary-treasurer PPMA  418 West Main Street  Senatobia, MS 38668  Phone: 601-562-4959, Fax: 601-562-7578  e-mail: eet@dixie-net.com

Date received: ____________