Please provide the following contact information:  
 

First & Last Name
Street Address
City
State
Zip Code
Work Phone
Home Phone
E-mail
IMA Member Number	(if Applicable, non-members welcome)

Attending the Following

          - 8 Hour CPE  $125.00 by 10/7/11;  $150.00 after 10/7/11

  - Past Presidents Dinner (additional charge)

   - Council Meeting on Saturday 10/15/11

-Check box if submitting payment via PayPal

Please do not attempt to put any payment information on this form; it is unsecure.

If you have comments, questions, etc. please feel free to fill in the text box below for a response.

To cancel a reservation, please complete your contact information and in the comments block below, type in "Cancellation"  or call Kathy Santos-Rezendes at 919-740-5289.   

	Registrations with payment must be received October 7, 2011 for on time registration
	Should you need to cancel your registration; requests for refunds submitted in writing by October 15th  will be honored subject to a $25 administrative fee.  Please remember to cancel your room reservation directly with the hotel.