Conference Registration Form
To register online, visit www.kaia.com/YAK
August 2-3, 2018
Milford, KS
Acorns Resort
(3710 Farnum Creek Rd
Milford, KS 66514)
Attendee
Member/Non-Member
Registration $100
Spouse/Guest BBQ
Child BBQ
BBQ/Entertainment Only $30
$15
$55
(30% discount for attendees driving 4 or more hours)
Total Amount
$_____________________
Name on License: ________________________________Agency/Company________________________
Company Address:________________________________City, State, Zip:__________________________
Email:__________________________________License #:______________License Exp. Date:__________
Mobile
Date of Birth:____________________________Phone:___________________________________
Work
Designations:__________________________________Job Title:__________________________________
Attending Guest/Spouse:__________________________________________________________________
Owner/Principal
Account Mgr.
Company Rep.
Role:
Agency Mgr.
Customer Service
Underwriting
Producer
IT
Other:_____________________________
Referred By:______________________________________________________________________________
Payment
If paying by credit card or check, please complete:
Check
Visa
MasterCard
American Express
Total Amount Due: $_________
Name on Card:_____________________________________________________________________________________________
Card #:______________________________________________________Exp. Date:_____________Security Code:___________
Billing Address:_____________________________________City:____________________State:__________Zip Code:________
Signature:_________________________________________
Lodging
Acorns Resort cabins have been secured. For reservations and details please call Joan Sutton 800-229-7048 x303 or email [email protected].
Cabin accommodations include single cabins, 5 bedroom cabins and lodge rooms.
Hotel Information:
Hampton Inn • 1039 S Washington St, Junction City, KS • (785) 579-6950
Cancellation Policy:
Cancellations received at least 10 business days prior to the conference
date are eligible for a full refund. Cancellations received less than 10
business days prior to the conference date are not eligible for a refund.
Return To KAIA:
E mail: [email protected]
Fax: (785) 232-6817
Mail: 815 SW Topeka Boulevard
Topeka, Kansas 66612