Requested Registration for Monthly Meetings

»Request registration online using this form then contacting the person below in reference to payment;

»or register by printing this form, then completing and mailing it with payment to:

Dietra Rosenkoetter
PMA Indiana District
Account Manager
Manufacturing Extension Partnership Center
Purdue University - TAP
6640 Intech Blvd., INTECH 10; Suite 120
Indianapolis, IN 46278-2012
Phone: 317-275-6812
Fax: 317-275-2375
dietra@purdue.edu

Please fill out this form for each person wishing to attend.

Requested Registration for the OCTOBER meeting

Your Information:
*Prefix	Mr. Mrs. Ms.
*First Name
*Middle Initial
*Last Name
Name on Badge
*Title
*Company
*Company Membership Status	Member Nonmember
*Company Address
Company Address
*Company City
*Company State/Province
*Company ZIP/Postal Code
*Company Country
*Company Phone
Company Fax
*E-mail
(A copy of this request for registration will be sent to the provided e-mail address. If you do not receive it within 24 hours, please contact Dietra.)

Special Arrangements/Requirements

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