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Mutual Insurance Day Registration Form

There is no charge to PAMIC Members for this event; however, it is necessary for you to register in order for us to have an accurate count for seating and lunch. Thank you!

* required field

name*  
nickname for badge   
company  
address*  
city / state / zip code*  
  P Co de*
phone*  
e-mail*  
   

Please check the events you will be attending:*

Monday, February 6:
All Sessions and Lunch
Afternoon Sessions Only – No Lunch

Tuesday, February 7:
Breakfast at the Capital with Legislators
Visits with my State Senator & Representatives

   
my state senator is:   
my state representative is:   

other legislators i would like to visit:   

PAMIC • 1017 Mumma Road, Suite 103 • Wormleysburg, PA 17043 • phone 717.303.0197 • fax 717.303.1501 • info@pamic.org