Please print this page and mail as indicated below:

REGISTRATION:

25TH ANNUAL CQIA CONFERENCE ON

QUALITY AND INNOVATION

TUESDAY, JUNE 5, 2012

9:00 am TO 2:00 pm

Saint Clements Castle in Portland, CT

Registration fee covers continental breakfast, seated networking lunch, 2012 Connecticut Best Practices Book, 2012 CQIA Innovation Prize plaques, and photographs.

_______ Please register me for the Conference. Attached is a check (no purchase orders) made payable to Connecticut Quality Improvement Award for $150 if received by Tuesday May 29th. ($200 if received after May 29th).

_______ Please register me for the Conference and bill my MasterCard, VISA or American Expresss card for $165 if received by Tuesday May 29th. ($215 after May 29th).

FOR EACH PERSON ATTENDING:

Name__________________________________

Title___________________________________

Organization_____________________________

Street address____________________________

Telephone_____________e-mail ____________

Card number______________ expiration______

Mail to CT Quality Improvement Award, PO 1396, Stamford, CT 06904-1396.

The Connecticut Quality Improvement Award Partnership, Inc., a 501(c)(3)not for profit Connecticut organization receives no money from either state or federal government. All funding comes from Sponsors, application fees and conference registration.