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

For additional guests, please use another form.

Registration Fees/Payment Information
Attendees / Full Fee / Daily Fee / # of Attendees / Total Due / Complimentary (explain)
Member / $250 / $100 / $
Nonmember / $350 / $125 / $
Guest/Youth / $150 / NA / $
Youth (Ages 17 & under) / $100 / NA / $
Region I FEIN: 54-1732328 Total: / $
All cancellations must be requested in writing and are subject to a $25 processing fee. Cancellations of prepaid registrations after July 1, 2012 or no-shows are non-refundable.
Method of Payment for Member Fees
Check or money order Jurisdiction Voucher Visa MasterCard Discover Am Ex
Name on Card: Card Number: / Expiration Date:
Method of Payment for Non-Member Fees
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 I, Inc. in U.S. funds. Registrations should be received by July 1, 2012.
Send your completed form to: AAMVA Region I, P.O. Box 353, Lowell, AR 72745 or e-mail to or fax to (703) 908-5868.

Registrant Name:

2012 Annual Region I 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
Monday, July 16 / Welcome Reception
Tuesday, July 17 / Continental Breakfast
Member Luncheon
Region I Fun Night
Wednesday, July 18 / Past Presidents’ Breakfast
Member Luncheon
Afternoon Business Sessions
Golf Outing (Lunch Included)
Mystic Seaport Tour/Aquarium (Lunch Included)
Thursday, July 19 / Buffet Breakfast
Awards Luncheon
Connecticut State Reception
Connecticut State Banquet
Friday, July 20 / Get-Away Breakfast