Group Registration for 2023 National Maternal Nutrition Intensive Course
Thank you for your interest in the National Maternal Nutrition Intensive Course.

This form is for groups and organizations who wish to set up a common registration portal. 

THIS FORM IS NOT FOR INDIVIDUAL REGISTRATION.

Please plan ahead if you have specific due dates for fiscal year end. The registration, billing and invoicing process can take up to 4 weeks.

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Email *
Your Name *
Your Phone *
Your organization/institution Legal name (this will be used for billing) *
Your organization/institution street address: *
Your organization/institution city: *
Your organization state: *
Your organization zip: *
Primary Billing Contact Name *
Primary Billing Contact Email *
Primary Billing Contact Phone *
How many will register for Virtual Webinar (live) MNIC (PubH X200) July 26-27, 2023 ($35 per person)? *
Please list names, if possible (email not necessary)
How many will register for Distance (recorded) MNIC (PubH X201) September 1-December 31, 2023 ($35 per person)? *
Please list names, if possible (email not necessary)
How will your organization pay for registration? *
Do you have a Purchase Order number? (if no, skip this question)
Do you need our W-9? *
Any questions?
A copy of your responses will be emailed to the address you provided.
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