2010 DE-MD-DC Annual Meeting Registration Form
AFTER APRIL 16, 2010 LATE FEES NOW APPLY - REGISTRATION FEES HAVE BEEN ADJUSTED AND NOW REFLECT $20.00 LATE FEES.
Final Registration Deadline is APRIL 23, 2010.
First Name:
*
Last Name:
*
E-mail:
*
Name for Badge
*
Day Phone:
*
Evening Phone:
*
Company Name:
Street Address 1:
*
Street Address 2:
City:
*
State:
*
Zip:
*
Credentials:
Delegate
Alternate
N/A
Membership Status:
*
Member
Division Member-At-Large
International Member-At-Large
Student Member
Guest/Non-Member
IAAP Membership #:
Year Joined IAAP:
Chapter:
*
Non Member/Guest
Black-Eyed Susan
Capital
Delaware
District of Columbia
DuPont
First State
Georgetown
Greater Baltimore
Hager
Harford
Montgomery County
Prince George's
Spires
Tidewater
Tri County
Wye Oak
Other - Enter Below
Chapter Other:
Certification:
*
CPS
CAP
CPS/CAP
N/A
First Time at Annual Meeting?:
*
Yes
No
Special Dietary Requirement?:
*
Yes
No
Dietary Requirements:
Any Disability Requirements?:
*
Yes
No
Disability Requirements:
MENU SELECTIONS - Friday Luncheon and Saturday Banquet...
Friday Luncheon Choice
*
Chicken Waldorf Wrap
Grilled Vegetable Greek Wrap
N/A Not Attending
Saturday Banquet Choice
*
Roast Strip Sirloin
Maple Glazed Salmon
Vegetable Puff Pastry
N/A Not Attending
EMERGENCY CONTACT INFORMATION...
Emergency Contact Name:
*
Emergency Contact Phone 1:
*
Relationship to you:
Emergency Contact Phone 2:
OPTIONAL - Are there any medical conditions you'd like us to be aware of in case of emergency?
On-site contacts - roommates or others traveling with you that can be contacted in the event of an emergency.
1) On-site Emergency Contact (Name & Phone)
2) On-site Emergency Contact (Name & Phone)
PAYMENT OPTIONS...
Payment options available for this event are as follows. PLEASE NOTE: Registrations will not be considered complete until full payment has been received. If you choose the installment option it is your responsibility to get your payments in by the due dates outlined in the registration packet.
PAYMENT Selection
*
CHECK - Full Payment
CHECK -Installment Option (1st 1/2 due by Feb 28, 2010 - 2nd 1/2 Due by Apr 16, 2010)
PAYPAL - Full Payments Only
CHECK PAYMENT Registrations - Click Here and Complete This Section...
CHECK Payment Registration Selections:
MEMBER/STUDENT - Full Registration ($170.00)
MEMBER/STUDENT - Friday Membership Luncheon ONLY ($50.00)
MEMBER/STUDENT - Friday Education Seminar ONLY ($45.00)
MEMBER/STUDENT - Saturday ONLY (includes Breakfast, Business Session & Banquet) ($115.00)
MEMBER/STUDENT - Saturday Banquet ONLY ($75.00)
MEMBER/STUDENT - OPTIONAL - Saturday System Source Training (not open to Delegates/Alternates) ($90.00)
NON-MEMBER/GUEST - Full Registration ($200.00)
NON-MEMBER/GUEST - Friday Membership Luncheon ONLY ($56.00)
NON-MEMBER/GUEST - Friday Education Seminar ONLY ($50.00)
NON-MEMBER/GUEST - Saturday Banquet ONLY ($86.00)
NON-MEMBER/GUEST - OPTIONAL - Saturday System Source Training ($104.00)
ENTER Check Total ($) Here (total must be manually entered):
Make checks payable to: 2010 Annual Division Meeting and mail to GREATER BALTIMORE CHAPTER, IAAP, Attn: 2010 Annual Division Meeting, c/o PO Box 9846, Loch Raven, MD 21284-9846. Please send a copy of this registration with your check. A fee of $35.00 plus any other bank fees will be assessed on all returned checks.
PAYPAL PAYMENT Registrations - Click Here and Complete This Section...
PAYPAL Registration Selections:
MEMBER/STUDENT Full Registration ($
170
)
MEMBER/STUDENT Friday Membership Luncheon ONLY ($
50
)
MEMBER/STUDENT Friday Education Seminar ONLY ($
45
)
MEMBER/STUDENT Saturday ONLY (includes Breakfast, Business Session & Banquet) ($
115
)
MEMBER/STUDENT Saturday Banquet ONLY ($
75
)
MEMBER/STUDENT OPTIONAL Saturday System Source Training (not open to Delegates/Alternates) ($
90
)
NON-MEMBER/GUEST Full Registration ($
200
)
NON-MEMBER/GUEST Friday Membership Luncheon ONLY ($
56
)
NON-MEMBER/GUEST Friday Education Seminar ONLY ($
50
)
NON-MEMBER/GUEST Saturday Banquet ONLY ($
86
)
NON-MEMBER/GUEST OPTIONAL Saturday System Source Training ($
104
)
Total : $
0
Before you finalize your registration and hit the Submit button you will want to print out this form using the Print options in your Browser. This will be your only opportunity to print the form data. There is NOT a print function within the form itself. Only you hit Submit you will not be able to come back and print your registration.
To finalize your registration, you must hit the Submit button below.
Thank you for using the On-Line Registration for the 2010 Annual Division Meeting, you will receive a confirmation within a few days.
Questions or Problems - email paernst1@gmail.com