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Print Clearly. One registrant per form (form may be
copied).
Incomplete forms will be returned unprocessed.
Name: __________________________________________
Home Address: ___________________________________
City: ____________________State: ____ Zip: __________
Day Phone: ______________________________________
CAMLT Member #: _______________________________
Renewal Date: _ _/_ _ CLS/MLT License/CPT Cert #: ______
Employer: ______________________________________
Work Address: __________________________________
City: ____________________ State: ____ Zip: _________
Work Tel: ________________________; ext. __________
E-mail Address: __________________________________
FAX #: ________________________________________
A. CAMLT MEMBERSHIP APPLICATION:
(Optional)
Submit completed membership application form w/ registration.
| Subtotal A: $ ___________ |
B. GENERAL REGISTRATION FEE
(Required of ALL Registrants)
| Pre-Registration fee (Only if
postmarked by 10/1/10): |
Pre-Registration fee (If postmarked
after 10/1/10) |
| Member: $30 |
Member: $40 |
| Non-member: $40 |
Non-member: $60 |
Students:
(FREE)
[ ] Check here if you are registering for the Student
Forum |
_________________________________________________
*Signature/phone # of Education Coordinator/Instructor required here for student
rate!
| Subtotal B: $ ___________ |
CAMLT LAB-PAC EVENTS
You
may pay by either VISA/MasterCard or by check.
Write separate check to: CAMLT LAB-PAC
Run/Walk/Stroll (Sat.., 10/23) _____ @ $25/ea. = ________
Luncheon (Sat., 10/23) ______ @ $35/ea. = ________
TOTAL LAB-PAC $ __________
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C. WORKSHOP SELECTION AND FEES: See
program for details and code numbers, then indicate workshop choice(s) by
entering code numbers below (e.g., 105-100):
| |
AM |
PM |
| Fri., 10/22 |
|
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| Sat., 10/23 |
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| Sun., 10/24 |
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| ___ CE's x $ _______ per CE = $
____________ |
Rates per CE Unit:
Members: $15.00
Non-members: $25.00 |
*Student Members: Free |
| Subtotal C: $ ___________ |
D. 20/20 DISCOUNT:
Only applies to active CAMLT
members who are currently enrolled for this benefit.
Total B: $ _____ + Total C: $ ________ = $ _______
Total ______ x 0.20 = Subtotal
D: ($ __________) |
E. SOCIAL EVENTS:
For Registrants and Guests
Fri. (10/22) Student Forum ___ (check here to register) (Student Forum is FREE)
Fri. (10/22) Lunch at Exhibits ____ @ $25 ea. = _____
Fun-Nite is half-price if you take 12 CE.
Register for half-price Fun-Nite: [ ] Yes [ ] No
Fri. (10/22) 1/2-off Fun-Nite: ___ @ $20 ea. = ______
Fri. (10/22) Fun-Nite: ___ @ $40 ea. = ______
Sat. (10/23) Installation Banquet: ___ @ $45 ea. = ____
| Subtotal E: $ ___________ |
GRAND TOTAL
(A+B+C-D+E):
$__________
Questions? Call us at 510-792-4441
METHOD OF PAYMENT:
( ) Check Payable to: 2010 Convention Fund
(Returned checks subject to a $20 fee)
( ) VISA or ( ) MasterCard (Check card type)
Card #: __________________________________
Exp. Date: _______
Signature: ___________________________________ |