International African American Prosthetic & Orthotic Coalition

Annual Meeting
26th -28th April 2012
Hyatt Regency Jacksonville- Riverfront
225 E Coastline Drive
Jacksonville, FL 32202

Registration Form

Late Fees Applied After 4th April.

Registrations not received by 6th April 2012 must register on site. Please register now.

Make checks payable to IAAPOC and mail the registration form to:

Reggie Mays
United Prosthetics and Orthotics
PO Box 56886
Jacksonville, FL 32241

Name:________________________________________________ Title:________________

Address:___________________________________________________________________

City:___________________________________ State:__________ Zip:________________

Phone(W)____________________(H)___________________(Fax)________________(W/H)

Names of additional attendees:___________________________________________________

____ 2012 Dues $100 Active, Associate & Honorary Membership                        $_______

____ 2012 Dues $50 Student Membership                                                        $_______

____ 2012 Meeting Fees for Paid Members- one of the above                            $_______
$125 Active, Associate & Honorary Members      Late Registration $150
$25 Student                                                    Late Student Registration $35

____ 2012 Meeting Fees for Non-members                                                       $_______
$150 Registration Late Non-member Registration $175

_____2012 Allied Health Professional Registration                                            $_______
$125 Registration                                            Late Allied Health Registration$150


Total # Attending:____                                                 Total Registration Fees $______

_____ 2012 Scholarship Donation                                                                    $_______

                                              Total Amount Included $______________________