Form

First Name.:*

Last Name:*

Certification:*

CAP CAP-OM N/A

E-mail:*

First Name for Badge:*

Day Phone:*

Cell Phone:

Evening Phone:*

Street Address 1:*

Street Address 2:

City:*

State:*

Zip:*

Company you work for:

Membership Status:*

Chapter Member Division Member-At-Large International Member Merited Member Associate Member Guest/Non-Member

Other Membership Status:

Division Officer Position please provide your title:

Business Meeting status*

Delegate Alternate N/A

IAAP Membership #:

IAAP Anniversary Date (mm/dd/yyyy):

Chapter:*

Other (i.e., DMAL, etc.):

First Time Attending the Annual Meeting?:*

No Yes

Dietary Requirements:*

No Yes, if yes indicate your preference below

Dietary Requirements:

Any Disability Requirements?:*

No Yes

Disability Requirements:

Member Friday Luncheon Choice*

Asiago Ravioli (vegetarian choice) Sauteed Chicken Breast with Dijon Sauce N/A

Non-Member/Guest Friday Luncheon Choice

Asiago Ravioli (vegetarian choice) Sauteed Chicken Breast with Dijon Sauce

Guest Name for Badge:

Member Saturday Banquet Choice*

Chicken Breast Pan Seared with Lemon Caper Sauce Grilled London Broil with Rosemary Demi Glace Vegetarian Pasta with Roasted Vegetables N/A

Non-Member/Guest Saturday Banquet Choice

Chicken Breast Pan Seared with Lemon Caper Sauce Grilled London Broil with Rosemary Demi Glace Vegetarian Pasta with Roasted Vegetables

Guest Name for Badge:

Emergency Contact Name:*

Emergency Contact Phone 1:*

Relationship to you:

Emergency Contact Phone 2:

OPTIONAL - Are there any medical conditions you'd like us to be aware of in case of emergency?

On-site contacts - roommates or others traveling with you that can be contacted in the event of an emergency.

1) On-site Emergency Contact (Name & Phone)

2) On-site Emergency Contact (Name & Phone)

Registration pricing (late fee is applicable if registering after May 7.:

Payment options are provided below. PLEASE NOTE: Registrations will not be considered complete until full payment has been received. If you choose the installment option it is your responsibility to get your check payments in by the due dates: 1st payment: March 5, 2012; 2nd payment: May 7, 2012. The returned check fee is $37.00.

If you are registering after May 7, 2012 there is a $25.00 late fee. Please check the late fee box above and include it with your registration payment.To complete your registration you must click on the PayPal button even if you are paying by check. This will add your registration information to our database. As a final step please send an email to our registration chair Shanthi Srinivasachar (shanthi4@verizon.net) so she can ensure that your registration information is received.

What do you receive with your registration fee?

Full Registration includes: Registration Materials; Registration Gift; Friday Seminar, Vendor Expo, Member Recognition Luncheon, and Evening Event; Saturday Business Session and Evening Division Awards and Installation Banquet

Friday Only Registration includes: Friday Seminar, Vendor Expo and Member Recognition Luncheon

Saturday Only Registration includes: Business Meeting and Evening Division Awards and Installation Banquet

Payment Option Selections*

CHECK - Full Payment - submit w/printed copy of registration form. Make checks payable to DE-MD-DC Division IAAP Annual Meeting; Mail Payment to: MCC-IAAP, Attn: DE-MD-DC Division IAAP Annual Meeting, PO Box 9032, Gaithersburg, MD 20898 CHECK - Installment Option available with full registration only (1/2 due March 5, 2012, final 1/2 May 7, 2012) - submit payments w/printed copy of registration form. Make checks payable to DE-MD-DC Division IAAP Annual Meeting; Mail Payment to: MCC-IAAP, Attn: DE-MD-DC Division IAAP Annual Meeting, PO Box 9032, Gaithersburg, MD 20898 PAYPAL - Full Payment w/online registration. Send an email to Shanthi Srinivasachar (shanthi4@verizon.net) upon submittal as a cross-check

Before you hit the Submit button, use the Print option on your browser to print a copy of the form for your records.

This will be your only opportunity to print the form data.

Thank you for using the On-Line Registration for the 2012 Annual Division Meeting, you will receive a confirmation within a few days.

2012 DE-MD-DC Division Annual Meeting and Education Forum Online Registration Form

Registration Deadline: May 7, 2012

MENU SELECTIONS - Friday Luncheon and Saturday Banquet

EMERGENCY CONTACT INFORMATION...