Annual Meeting Registration

Western Section 109th Annual Meeting
Double Tree Hotel - Colorado Springs, Colorado
September 15-18, 2013

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		$380.00
Spouse Fee		$200.00
Non-Member Fee		$480.00


		Total

All registrations must be recieved by September 10th. 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

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 15-18, 2013
	Last Name	First Name	M.I.	Email Address:
Company Name:
Address				Phone Number:	Fax Number:
City:				State	Zip-Code
Display Booths are $750.00 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: $