AMBA 11th 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 (Up to 3 members)

      List All New Members Here __________________________________________________________________________________

      Member Pricing Non-Member Pricing

       

       1 Attendee $429 (early registration (thru Aug. 2011)

       

       1 Attendees $629

       2 Attendees $808 ($429 + $379) Early Registration

       2 Attendees $1208  ($629 + $579)

       3 Attendees $1187 ($429+$379+$379)

       3 Attendees $1,787 ($629+$579+$579)

          

      No refunds after Aug. 14, 2011.  80% Refund prior to June 14, 2011 

       

      List All Conference Attendees Here ___________________________________________________________________

      ___________________________________________________________________

      ___________________________________________________________________

       

       Attending Chapter Officer's Meeting $0 (Must be a Chapter Officer or NAB to Attend)

       Attending National Advisory Board Meeting $0

      Order Total $__________            (See Refund Policy Above)

      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.