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ASSIST Convention
2001 Registration Form
October 11-13,
2001 The Ramada
Plaza Hotel Fort
Worth, Texas
Please print out and
complete this registration form and mail to the following address along with your
check payable to ASSIST. You may also pay using your VISA
or MasterCard by including
your card information at the bottom of this form.
Bob Kenney
8585 N. Stemmons Freeway Suite M-24
Dallas, Texas 75247
or FAX this form to Bob at: (214) 637-1443
Cancellation Policy:
Refunds, less a $30.00 processing fee, will be granted if requested in
writing and received prior to
September 1, 2001. After September 1, 2001, no refunds will be
made. A substitute can attend if we receive notification
by October 10, 2001. ASSIST reserves the right to substitute
instructors and make necessary modifications to the
program/agenda.
I have read the
Cancellation Policy and wish to attend the ASSIST 2001 Annual
Convention.
Name:
______________________________________________ Social Security No.
(for CE Certificates): _________________________
Firm Name and address:
__________________________________________________________________________________________
Attendee address:
__________________________________________ City:
_______________________ State: ______ Zip: ________
Telephone:
__________________________ Fax: ___________________________
Email address: ______________________________
Spouse / Guest name:
_________________________________________________
| Fee
Enclosed: (Must be received by September 1, 2001) |
|
Late
Registration: (Received after September 1, 2001) |
| _____
$150 ASSIST Member or $200 Non-Member |
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$180 ASSIST Member or $200 Non-Member |
| _____
$ 75 Spouse/Guest (Limit 1) |
_____
$ 85 Spouse/Guest (Limit 1) |
Note:
Spouse/Guests are not eligible for CE Credits. Those
wishing to attend the speaker functions should register as a
member or non-member. |
Note:
Spouse/Guests are not eligible for CE Credits. Those
wishing to attend the speaker functions should register as a
member or non-member. |
| _____
$150 Regular 2001 Voting Membership Dues (if not yet paid) |
_____
$150 Regular 2001 Voting Membership Dues (if not yet paid) |
| _____
$ 45 Thursday evening activity (per person) |
_____
$ 55 Thursday evening activity (per person) |
| _____
$ 10 Saturday Breakfast & Business Meeting Attendance Only |
_____
$ 10 Saturday Breakfast & Business Meeting Attendance Only |
| _____
Total enclosed |
_____
Total enclosed |
VISA [
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] Credit Card Number:
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Exp Date (mm/yy):
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or
9-Digit Bank Routing
Number: [ ] [
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Bank Account Number:
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[
] I cannot attend but would like to receive ASSIST
Membership information.
For more information,
please contact Bob Kenney, ASSIST DFW Chapter President at (214)
637-6410 ext 25.
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