First Name: *

Last Name: *

Address: *

Address 2:

City: *

State/Province: *

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ZIP/Postal Code: *

Country:

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Email Address: *

Home Phone:

School (if nursing student):

Address where you are registered to vote, if different from your mailing address above.
(Please check your voter registration card.)

Voting Address:

Address 2:

City:

State/Province:

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ZIP/Postal Code:

Senate:

House of Representatives:

DIETARY NEEDS:

List Here if Applicable

$30 - Non-MNA member

$20 - MNA member

$10 - Nursing Student

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February 27, 2008 is the deadline for registrations.