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AMBA 4th Annual National Conference Registration Form - October 13th – 15th 2004
Attendee Information (Must be AMBA Member to Attend) |
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Last Name ________________________________First Name ____________________________MI __________
Business Name______________________________________________________________________________
Address ____________________________________________________________________________________
City _________________________________________________ST __________________Zip________________
Wk Phone ________________________Home Phone ______________________Fax______________________
Email Address_______________________________________________________________________________
I’m already a member - Membership #_____________________ Expiration Date ___________________
My membership is under the name of __________________________________________________________
I’m not a member – please register me
___ Individual Membership $89
___ Business Membership $150 (up to 3 members Include a Separate Form for Each Member)
___ $279 each (Early registration through August 22, 2004) ___ $259
each addl. business member attendee (early registrations only) Total Number
_____ ___ $299
each (Late registration August 23, 2004 and after, no exceptions) ___ $279 each addl. business member attendee (late registration) Total Number _____ ___ $10
Pre-Conference Meet and Greet Session, Wednesday, October 13, 2004 Total Number
of Pre-Conference attendees _____ I have a food allergy to ____________________________________________
___ I registered and paid online
Order Total $__________________ (No refund or cancellation after Sept. 12, 2004)
Charge my Visa MasterCard Discover American Express
Card #___________________________________ Exp. Date________________
Cardholder Name___________________________________________________
Signature__________________________________________________________ (Charge will appear as AMBA)
Make Checks Payable to:
AMBA 4297 Forrest Drive Sulphur, OK 73086
Fax Credit Card Registrations to: (580) 622-5810
Questions? Call our Conference Coordinator at (580) 622-2624 or email Larry@brightok.net
Conference Held at Orleans Hotel and Casino http://www.orleanscasino.com The American Medical Billing Association will not accept liability for damages of any nature sustained by participants or their accompanying persons or loss of or damage to their personal property as a result of the Conference or related events. |