AMBA 5th Annual National Conference

Registration Form - October 12^th – 14^th 2005

Attendee Information (Must be AMBA Member to Attend)

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 $99

___ Business Membership $199 (3 members)

___ $329 each (Late registration August 19, 2005 and after, no exceptions)

___ $309 each addl. business member attendee (late registration) Total Number _____

___ $10 Pre-Conference Meet and Greet Session, Wednesday, October 12, 2005

Total Number of Pre-Conference attendees _____

Name and email of addl. attendee #1 ____________________________________________

Name and email of addl. attendee #2 ____________________________________________

I have a food allergy to ____________________________________________

___ I registered and paid online

Order Total $__________________ (No refund or cancellation after Sept. 9, 2005)

Charge my  Visa  MasterCard  Discover  American Express

Card #___________________________________ Exp. Date________________

Cardholder Name___________________________________________________

Signature__________________________________________________________

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 Riviera Hotel &Casino

http://www.rivierahotel.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