MPCA / MACA : Membership and Conference Registration Form

2005 Membership and Conference Registration Form

Name

Business Address
Department

College or University

City/State/ZIP

Phone

Fax

E-mail
(We will use this only for conference and membership announcements, no junk.)
Home Address
Street

City/State/ZIP

Phone

Fax

E-mail
(We will use this only for conference and membership announcements, no junk.)
Where do you prefer snail mail to be sent?
Business Address
Home Address

Circle one
if applicable:

Student

Retired

Unemployed

Fees
Registration Fee: $_____ ($90 for faculty and other professionals; $70 for student, retired, or unemployed)
Membership Fee: $_____ ($60/year for faculty and other professionals; $40/year for student, retired, or unemployed; membership is for calendar year 2005; membership fee is due with this registration form unless you have already paid)
Late Registration Fee: $_____ ($15 on-site or received after September 15, 2005)
Total enclosed: $_____
Payment must be drawn on US bank or International Money Order and made payable to Northern Illinois University. Badge and receipt will be available for pickup at the conference. All conference participants must be members of MPCA/MACA and must pay the registration fee.
Mailing address
Send this form and payment (payable to NIU) to
Gary Burns
Department of Communication
Northern Illinois University
DeKalb, IL 60115
Thank you!