2007 NAABC National Conference

 REGISTRATION FORM
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Name: ____________________________________ (as you want it to appear on your CE certificate(s))

Address: _____________________________________________________

   ______________________________________________________

Phone:  ___-___-_____   Fax: ___-____-______Email Address: ________________________________

Home State for CE credit: ________     License or Social Security Number: ________________________                                                                                                                    (Which ever is used by your state’s insurance department)

Please complete this form and return to us with payment or payment arrangements ON OR BEFORE

March 31st, 2007 TO RECEIVE AN “EARLY BIRD” DISCOUNT

REGISTRATION:  (Please Check)

1)           I will Attend the Convention on Monday, April 30th              Yes___              No___

                  Cost:  NAABC Members $99.00     Non-members $149.00

2)           I will Attend the NAABC Information Meeting on Monday evening, April 30th     Yes___              No___

                  This meeting will be moderated by Ron Dobervich to address ‘Where do we go from here’ as an organization

                                          There is no cost for this meeting.

3)           I will Attend the Advanced CBC Course                      Tuesday, May 1st        Yes___              No___

Tuition:  If received on or before March 31st     $99.00     If received after March 31st    $139.00

(These prices for the Advanced course are reduced due to the convenience of location.  They may be subject to change after the convention)

PAYMENT OPTIONS:

_____ Check or Money Order     

_____ I have enclosed a check or money order for $________ as full payment.

_____ Credit Card      completion of the credit card information below is required.  YOUR CREDIT CARD CAN ONLY BE BILLED IF YOU AUTHORIZE NAABC TO BILL YOUR CREDIT CARD FOR YOUR PAYMENT OR DEPOSIT.

                                          Please circle card type:    AMEX    Visa    MasterCard

Card # ___ ___ ___ ___   ___ ___ ___ ___   ___ ___ ___ ___   ___ ___ ___ ___    Expiration date ___ ___ / ___ ___

Payment Amount:  $__ __ __.__ __    Printed name of cardholder ________________________________

                                          Signature __________________________________   Date________________

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You may either mail the completed form to the address below or fax to 715-273-0147

EBAS, P.O. Box 720,  Ellsworth WI 54011

Or Register online at www.naabc.com