Full Name: / Badge Nickname:
Organization:
Title:
Mailing Address:
City: Jurisdiction: Zip:
Email Address:
Phone: / Fax:
Emergency Contact Info: Name: Phone Number: Cell Phone Number:
Guest/Youth Information
Guest/Youth #1 Name: / Youth Age: Youth Shirt Size:
Guest/Youth #2 Name: / Youth Age: Youth Shirt Size:
Guest/Youth #3 Name: / Youth Age: Youth Shirt Size:
Guest/Youth #4 Name: / Youth Age: Youth Shirt Size:
Registration Fees/Payment Information
Attendees / Fee / # of Attendees / Total Due / Complimentary (explain)
Member / $250 / $
Nonmember / $300 / $
Guest / $150 / $
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 16, 2013 or no-shows are non-refundable.
Method of Payment for Registrant
Check or money order 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. Make check or money order payable to AAMVA Region II, Inc. in U.S. funds. Registrations should be received by May 27, 2013. DO NOT SEND CREDIT CARD INFORMATION BY EMAIL
Send completed registration to: AAMVA Region II, P.O. Box 464, Lowell, AR 72745 or by e-mail to or by fax to 703-908-5868
Registrant Name:
2013 Annual Region II ConferenceEvent Registration
Please indicate the activities you and your guest(s) 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 YouthsSunday, June 9 / Welcome Reception
Youth Welcome Reception
Monday, June 10 / Continental Breakfast
Guest/Youth Event – Georgia Aquarium – Lunch provided
Member Luncheon
Region II Family Night – Zoo Atlanta
Tuesday, June 11 / Past Presidents’ Breakfast
Golf Tournament – Stone Mountain Park (Lunch provided)
Optional Event – Stone Mountain Park ($10 lunch voucher provided)
Wednesday, June 12 / Buffet Breakfast
Youth Event – World of Coke, CNN Studio Tour, Centennial Olympic Park (Lunch provided)
Guest Event – The Carter Library & Museum, The ML King Jr. Center (Lunch provided)
Awards Luncheon
Georgia State Reception
Georgia State Banquet
Youth Banquet
Thursday, June 13 / Get Away Breakfast
Project Code: 111-222-004