Midwest Chapter - AAOP - Registration Form

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ONLINE REGISTRATION FORM

Fall 2009 Meeting
Midwest Chapter AAOP
November 7th, 2009

Limited Space! Register ASAP

Each full registration includes: Member's registration, continental breakfast and lunch.

Location: Scheck & Siress, Hickory Hills

Address: 8641 W 95th Street
Hickory Hills, IL 60457

Name:		Company:
Address:		Phone:
City:		State/Zip:
E-Mail:		Fax:
Certificate type and number:

Fees: (check all that apply)
Midwest Chapter AAOP Member			$125.00
Eligible Non-member and BOC & Allied Health Professional			$150.00
Techinicians, Students, and Emeritus			$60.00

Not a Midwest Chapter Member? Go here and sign up!

Special Requirements:

Total Registration Fees:

** Three weeks notice for cancellation to recieve partial refund.

Notice: You will be redirected to PayPal.com for payment processing. You may use a credit card by scrolling down on the PayPal site to the “Don’t have a PayPal Account” Section of the PayPal Website.