ATTENDEE & GUEST REGISTRATION FORM October 31 - November 2, 2018 • Gaylord Palms Resort • Orlando, FL ATTENDEE REGISTRATION INFORMATION (please type or print clearly) REGISTRATION FEES EARLY Name ON-SITE by 10/03/18 after 10/03/18 NAILBA Member Agency Principal Designations Badge Name Agency/Company Name (One (1) per agency) FREE Member Emeritus $395 FREE $595 NAILBA Member Agency Staff Address City REGULAR by 09/21/18 State Zip 2nd person (or more) attending $595 $995 Exhibitor or Sponsor FREE FREE $595 Two (2) complimentary registrations with CONFIRMED Sponsor Agreement Phone Email Emergency contact $250 Additional Attendee $595 Guest $395 This category is for individuals who are not employed in the life brokerage community and are attending in a social capacity only. Emergency contact phone Will you attend the Mooers Award Dinner on Thursday, November 1, 2018 (no additional fee) ? Yes No This is the first time I have attended the NAILBA Annual Meeting. I require assistance to fully participate. GUEST REGISTRATION INFORMATION Booth Attraction - Support Staff PAYMENT INFORMATION Total Amount Due $ Discount Code (if applicable) Check (check is enclosed) (please type or print clearly) This category is for individuals who are not employed in the life brokerage community and are attending in a social capacity only. Check # Amount $ Credit Card VISA MasterCard Name Credit Card # Badge Name Expiration Date Will your guest attend the Mooers Award Dinner on Thursday, November 1, 2018 (no additional fee) ? Yes No My guest requires assistance to fully participate. American Express CC Security Code Name on Card Signature CANCELLATION POLICY THREE WAYS TO REGISTER EMAIL FORM TO firstname.lastname@example.org / credit card payments ONLY FAX your registration to 703.383.6942 / credit card payments ONLY MAIL your registration, with check made payable to NAILBA, to: NAILBA 37 11325 Random Hills Road, Suite 110 Fairfax, VA 22030 A $250 fee will be charged for any cancellation received on or before October 19, 2018. No refunds will be granted after October 19, 2018. All registrations, changes and cancellations must be received in writing. Registration fees must accompany registration forms. NAILBA does not invoice for registration fees. Questions? Contact NAILBA at email@example.com or 703.884.1525.