AMBA 6th Annual National Conference

Registration Form - October 19th – 20th 2006

 

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 (Early registration through September 15, 2006)
___ $388 each (Late registration after September 15, 2006, no exceptions)

___ Attending Local Chapter Officer's Meeting October 18, 2006 (no charge)


___ $309 each addl. business member attendee (early registration, through September 15, 2006)
Total Number _____

___ $368 each addl. business member attendee (Late registration after September 15, 2006)
Total Number _____

 

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 September 15, 2006)

 

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 Adams Mark Hotel, Dallas

http://www.adamsmark.com/dallas/index.asp

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