Submit Registration Form Below by Fax:

 

 

AMBA 10th 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 ________________ or I cannot eat the following meat: _______________________

___ I am staying at Planet Hollywood

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 $498

 

___ 1 Attendees $598

___ 2 Attendees $946 ($498 + $448)

___ 2 Attendees $1146 ($598 + $548)

___ 3 Attendees $1394 ($498+$448+$448)

___ 3 Attendees $1,694 ($598+$548+$548)

    

 

List All Conference Attendees Here_______________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

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

___ Attending National Advisory Board Meeting $0

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 • 2465 E. Main • Davis, OK 73030

Fax Credit Card Registrations to: (580) 369-2703

Questions? Call our Conference Coordinator at (580) 369-2700 or email Larry@brightok.net

Conference held at Planet Hollywood Resort & 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.