Annual Meeting Registration

Western Section 107th Annual Meeting
Galt House Hotel - Louisville, Kentucky
September 18-21, 2011

Secretary Mike Forister
Email: mforiste@wyoming.com
Fax Number: 307.638.4427

IAEI Western Section
413 W. 2nd Avenue
Cheyenne, Wyoming 82001

Meeting Registration Form

Website: http://IAEI-Western.org

Attendee Information

What are you registering for? Attendee Sponsor Booth / Donation

Name:

First Name on Badge:

Last Name

First Name

M.I.

Email Address:

Address

Phone Number:

Fax Number:

City:

State

Zip-Code

Representing

Social Security Number:

(Last 4 Digits Only)
Required for CEUs

Spouse Attending (Name):

First Name on Badge:

REGISTRATION FEE	PRE-REGISTRATION (Must be Recieved by Sept 1.)	LATE REGISTRATION (If Recieved after Sept. 1)	AMOUNT PAID
Member Fee Number	$245.00	$300.00
Spouse Fee	$150.00	$175.00
Non-Member Fee	$345.00	$400.00


		Total

All registrations must be recieved by September 9th. There will be no at-door registration.

Please indicate if you plan to attend the following events that are included with your registration: (YES or NO)

Sunday Evening Welcoming Reception

Tuesday Evening Banquet

River Boat Ride Monday Evening

Spouse's Program.... Please indicate if you plan to attend the following events for the Spouse Program: (YES or NO)

Monday Spouse Program Events Tuesday Spouse Program Events

Sponsor Booth and Donations

Sponsor Booth:
Contact:				September 18-21, 2011
	Last Name	First Name	M.I.	Email Address:
Company Name:
Address				Phone Number:	Fax Number:
City:				State	Zip-Code
Display Booths are $550.00 per booth. Do you wish to sponsor a display booth? Yes
Perferred Display Booth Number Alternate Booth Numbers (enter 3)

(COFFEE/SODA BREAK SPONSOR) : I/We would like to sponsor a Coffee/Soda Break for $500.00 Yes
(PROGRAM AD SPACE) : I/We would like to purchase Program Booklet Ad Space: $
(DONATIONS) : I/We would like to submit a donation to the Western Section IAEI in the amount of: $