WIM Conference Registration Form

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					                                             Treasurer Use Only:
Registration Received: ______         Payment Received: ______ Check #______                      Cash: ______

                         WIM Conference Registration Form
         Please complete only one registration form per person and PRINT clearly.

         Contact Information
                Street Address
                City, State, Zip Code
                E-Mail Address

         Check one: Student ___         Faculty ___     Guest ___    WIM Officer ___      WIM Officer Adviser ___

         Friday Tour Selection
         Please indicate your first (1), second (2), and third (3) choices for your tour selection. Some tours will
         have limited availability depending on a tour stop’s ability to accommodate groups.

          ___ Fashion Merchandising

          ___ Food, Nutrition, Dietetics, and Hospitality

          ___ Human Services

          ___ Interior Design

          ___ Variety

         Registration Payment
         Registration must be postmarked by January 27, 2010.
         Payment must accompany registration or late fees will apply.
         Registration is not complete without payment.
         Receipts for registration will be distributed at the conference.

         _______ $60 Early Bird Registration Fee   (Postmarked on or before January 27, 2010.)
         _______ $70 Late or On-site Registration Fee   (On-site must pay at conference;
                                                        mailing payment after conference is not permitted.)

                                   Please make checks payable to:          WIM Conference

         Please return this registration form and your registration payment to:
                                                    Lauren Zeliff
                                          Northwest Missouri State University
                            312B FCS Dept., 800 University Drive, Maryville MO, 64468-6015

         If you have questions, please contact: Email: s202143@nwmissouri.edu
                                                Phone: (660) 541-0013 or (660) 562-1169