AMBA 7th Annual National Conference Registration Form

First Name ________________________________Last Name ____________________________MI __________

Business Name______________________________________________________________________________

*Address ____________________________________________________________________________________

*Your address must match the credit card billing statement address

City _________________________________________________ST __________________Zip________________

Wk Phone ________________________Home Phone ______________________Fax______________________

Email Address_______________________________________________________________________________

I have a food allergy to ____________________________________________

Please select the items you would like to register for below.  If you are not a current AMBA member and would like to join, you may do so below, or you can attend the conference as a Non-Member. Please complete one form for each attendee.

___ Individual Membership $99

___ Business Membership $199 (3 members)

List All New Members Here______________________________________________________________________

Member Pricing	Non-Member Pricing
___ 1 Attendee $398	___ 1 Attendees $498
___ 2 Attendees $776 ($398 + $378)	___ 2 Attendees $976 ($498 + $478)
___ 3 Attendees $1,154 ($398 + $378 + $378)*	___ 3 Attendees $1,454 ($498 + $478 + $478)

List All Conference Attendees Here_______________________________________________________________

___ Attending Local Chapter Officer's Meeting $0 (Must be a Chapter Officer to Attend)

Order Total $__________________ (No Refunds)

I am paying by       Credit Card       Check or Money Order

Card #_________________________________________ Exp. Date________________

Card Security Code ___________ (from back of card - 3 or 4 digit code)

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 Harrah's Hotel & Casino - Las Vegas, NV

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.