NSMH National Registration Form

*indicates required field

E-Mail Address* Password
First Name* Last Name*
Your Current Mailing Address
Street* City*
State or Province* Zip or Postal Code*
Country Current Phone No. ()-
Permanent E-Mail Address
Gender Date of Birth
Name of a company for sponsors
Ethnic Origin
If other - Ethnic Origin
Mail my NSMH Conference Badge to this address:
Street  * City *
State * Zip *
 Payment Options (Circle One) Visa   MasterCard  Check  Money Order
Credit Card Number:*    
Expiration Date: * /    
Name on Credit Card: *    
CVV Number *    

National Conference Registration
First Time Attendee Yes   No
Ethnicity :
American Indian Asian/Pacific Islander
Caucasian Latino
Native American Other 
 I am a ...  :
Member Sponsor (representative)
Delegate Chapter President
Advisor Alumnus
 Registration Fees
Conference Registration Fee : ARRIVE by January 25,2019  Onsite
Members & Chapter Advisors $195.00 $230.00
Alumni $205.00 $240.00
Sponsors & Non-Members $250.00 $285.00
    *Awards Gala Tickets : X $100.00 each.

(Awards gala tickets are NOT included for sponsor and non-member registrants. Members and alumni do NOT need to purchase gala tickets; they ARE included with your registration)

 Registration & Cancellation Policy 

Registration Deadline: All registration forms must ARRIVE or completed via the Internet by January 18, 2011 to be eligible for the discounted rate. AFTER JANUARY 26,2009 PLEASE REGISTER ON-SITE ONLY.  No exceptions.

Refund Policy: All requests must be received in writing to the National Headquarters office via fax, mail or email (hq@nsmh.org) no later than January 18, 2011..  All refunds will be subject to a $50.00 service fee.  After January 16, 2009, no refunds will be processed.  No exceptions.
Registration Transfers: All requests for transfer of registration from one registrant to another must be received in writing to the National Headquarters office via fax, mail or email (hq@nsmh.org) no later than January 18, 2011.  Registration transfer requests much include the name and payment type of the original registrant; the replacement registrant must be the same registration type as the original registrant.  NO TRANSFERS ONSITE.
 State any dietary/Special meal requirements:
  Type the code shown*  Change Text

Contact The office to change any information you can not edit here.  Be sure to include your Member ID and your Name as it is shown above.

 6933 Commons Plaza, Suite 537
Chesterfield, VA 23832
Phone: (703) 549-9899
Fax: (703) 539-1049


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