Conference and Exposition - IACLEA

Delegate Registration FormIACLEA 47th Annual Conference and ExpositionJune 25-29, 2005 • Kansas City, Missouri Check if this is a new address Check if you are a first-time attendee Check if you are driving to the conferenceName ______________________________________ Title __________________________________________________________Institution __________________________________________________________________________________________________Address ___________________________________________________________________________________________________City __________________________ State/Province ___________ Zip ________________ Country ______________________Business Telephone _____________________________________________________________ Fax _______________________E-mail ________________________________________ Nickname for Badge __________________________________________Spouse/Guest Name for Badge ________________________________________________________________________________Children’s Names for BadgesName:_____________________________________________________________________ Age: _____________Name:_____________________________________________________________________ Age: _____________Name:_____________________________________________________________________ Age: _____________Please indicate the events you will be attending: Sunday Exhibit Hall Lunch Sunday Host Special Event Wednesday BreakfastEmergency Contact ____________________________________________________________ Phone _______________________ Special Needs (please list) ___________________________________________________________________________________Registration fee includes: Admittance into scheduled workshops and general sessions (6/25-29), admittance into the ExhibitHall during exhibit hours, name badge for the delegate; Sunday lunch and reception in the Exhibit Hall, Sunday night event,Monday continental breakfast in the Exhibit Hall, Wednesday General Session Breakfast, and coffee breaks.REGISTRATION FEES: Before April 30 After April 30(Check all appropriate boxes) IACLEA Member Institution — 1st Attendee $395 $445 IACLEA Member — 2nd Attendee or More $345 $395 Retired/Honorary Members $345 $395 Non-Member Institution — 1st Attendee $460 $510 Non-Member — 2nd Attendee or More $435 $485Grand Total — (U.S. Funds Only): $_______ $_______METHOD OF PAYMENT: (Please check appropriate boxes) Check enclosed made payable to: IACLEA Annual Conference Purchase Order # __________________________ (Fed. I.D. #58-1410882) MasterCard VISA AMEXCard # ___________________________________ Exp. Date _____________Signature ____________________________________ Date _____________SEND REGISTRATION FORM AND PAYMENT TO:IACLEA Annual Conference342 North Main Street, West Hartford, CT 06117-2507(please see other side for registration policies and procedures)THREE EASY WAYS TO REGISTER:Complete the form on theIACLEA Web site atwww.iaclea.orgorBy Fax:(860) 586-7550orBy Mail:IACLEA Annual Conference342 North Main StreetWest Hartford, CT 06117-2507USA