MW MSD Approved Provider Annual Fee Payment Form

Address *

Contact Name *

First Name Last Name
Contact Title *
Preferred Phone *

Area Code Phone Number
Preferred Email *
Educational Activity Title and Date Provided:
Example: ABCs of Event Planning; provided 12/12/19
Select a payment type *

Credit Card Check
Activity File Review Fee *

$200.00
Please make checks payable to:

Midwest MSD
3340 American Ave. Suite F
Jefferson City, MO 65109
* Activity File Review payments are due prior to reviewing the file(s) submitted.
value

Activity File Review Fee *

Activity File Review $ 200.00