Mississippi LPN Association
50^th Anniversary

Unwavering Boldness
Exceeding Expectations
Caring with Confidence

Convention Registration

To receive the CEU credit, all Information must be completed as requested.

Is Payee different person than Attendee?*
Select Regional Meeting
Payee Information
Payee Name*
As appears on LPN license
First Middle Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
NFLPN Member Number
Mississippi LPN License Number
Attendee Information
Attendee Name*
As appears on LPN license
First Middle Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
NFLPN Member Number
Mississippi LPN License Number
Registration Type*
March 1st Deadline, No Exceptions. Late Registration is $375. No refunds will be issued after March 15th. Any request for refunds must be in writing address to linda.shows@mslpn.org or MLPNA PO BOX 1495 Laurel, MS 39441. The MLPNA Board must review refunds.
Credit Card

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name

Convention