Registrant Information
Full Name: / Name for Badge:
Organization:
Title:
Mailing Address:
City: Jurisdiction: Zip:
Email Address:
Phone: / Fax:
Emergency Contact Info: Name: Phone Number:
Guest/Youth Information
Guest/Youth #1 Name: / Youth Age: Shirt Size:
Guest/Youth #2 Name: / Youth Age: Shirt Size:
Guest/Youth #3 Name: / Youth Age: Shirt Size:
Guest/Youth #4 Name: / Youth Age: Shirt Size:

For additional guests, please use another form.

Registration Fees/Payment Information
Attendees / Fee / # of Attendees / Total Due / Complimentary (explain)
Member / $250 / $
Nonmember / $300 / $
Guest / $100 / $
Youth (Ages 17 & under) / $75 / $
Region II FEIN: 54-1732394 Total: / $
All cancellations must be requested in writing and are subject to a $25 processing fee. Cancellations of prepaid registrations after May 24, 2012 or no-shows are non-refundable.
Method of Payment for Registrant
Check or money order Jurisdiction Voucher Visa MasterCard Discover Am Ex
Name on Card: Card Number: / Expiration Date:
Method of Payment for Guest/Youth
Check or money order Visa MasterCard Discover Am Ex
Name on Card: Card Number: / Expiration Date:
Payment may be in the form of a check, credit card, or money order. Registrations received without payment will be invoiced upon receipt. Jurisdictional vouchers or purchase orders will be invoiced.Make check or money order payable to AAMVA Region II, Inc. in U.S. funds. Registrations should be received by May 21, 2011.
Send completed registration to: AAMVA Region II, P.O. Box 464, Lowell, AR 72745 or by e-mail to or byfax to 703-908-5868

Registrant Name:

2012Annual Region II Conference
Event Registration

Please indicate the activities you and your guests plan to attend. Tickets may be issued for some conference activities, so please check only those events you will actually attend.

Date / Activity / Self / Number of Guests / Number of Youths
Sunday, June 10 / Welcome Reception
Monday, June 11 / Continental Breakfast
Guest/Youth Event – Blenko Glass Company tour/Heritage Farm Museum & Village: Blenko is an American institution, the exquisite color, skilled craftsmen, and imaginative designs have made Blenko famous in the time-honored craft of hand-blown glass.Step back in time at the Heritage Farm Museum and Village. Lunch Provided.
Member Luncheon
Region II Family Night–Enjoy
Tuesday, June 12 / Past Presidents’ Breakfast
Golf Tournament– Edgewood Country Club
Optional Event – White Water Rafting
Optional Event –Zip Lining & Coal Mining Camp Tour
Optional Event –Hatfield & McCoy ATV Tour ( limited to 20 adults)
Wednesday, June 13 / Buffet Breakfast
Guest/Youth Event –
Awards Luncheon
West Virginia State Reception
West Virginia State Banquet
Youth Banquet
Thursday, June 14 / Get Away Breakfast