Name:

Company:

Address:

Phone:

City:

State/Zip:

E-Mail:

Fax:

Certificate type and number:

Midwest Chapter AAOP Member

$175.00

$225.00

Eligible Non-member and BOC

$225.00

$275.00

Allied Health Professional

$175.00

$225.00

Techinicians, Students, and Emeritus

$100.00

$125.00

Single Day Regestration: (includes lunch)

Please Indicate:

Friday

Saturday

Midwest Chapter AAOP Member

$100.00

$125.00

Eligible Non-member and BOC

$125.00

$150.00

Techinicians, Students, and Emeritus

$75.00

$100.00

If you have a foursome arranged please contact Jason Tamalunas at (269) 983-6118
or email him at jasont@americanlimb.com. We will attempt to accommodate foursomes and twosomes as requests are made. Please include fee for golf outing with registration.

Golf Outing

$95.00

Active Member Fee

$35.00

Special Requirements:

Total Registration Fees:

Vendor Registration
Company Name
Attendee Name(s)
Each Qty. Total Table(s)- 8ft. x 2.5ft.- Includes 2 attendees, 2 chairs & skirting $300.00 Electric Outlet $20.00 Golf (cart & fees) $100.00 Golf Participant Name(s) Manufactures Cocktail Sponsorship (Limit 4) $200.00 Hole Sponsorship (Golf)- Announced at Awards Presentation & Sign on course $100.00 Lunch/ Refreshment Cart Sponsorship (Golf/ Limit 3) $200.00 TOTAL DUE

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