(PLEASE PRINT OR TYPE)

NAME _________________________________________________

TITLE ________________________________________________

MAILING ADDRESS_______________________________________

CITY_______________________STATE____________ZIP_____________

I WILL [__]/WILL NOT [__] BE PRESENT AT THIS ANNUAL CONVENTION.

MY LADY WILL[___]WILL NOT[___]ACCOMPANY ME. [NAME___________________]

PLEASE RESERVE HOTEL ROOMS AS FOLLOWS;

        [___] Double @ $72.00 + TAX

        [___] King @ $72.00 + TAX

I EXPECT TO ARRIVE ___________DATE ___________TIME

I WILL BE TRAVELING BY AUTOMOBILE [___]

AIRLINE [___] _________________________FLIGHT # ________________

I WILL DEPART ___________________________________

PLEASE NOTE:
ROOM WILL BE HELD UNTIL 6:00 P.M. UNLESS GUARANTEED BY CREDIT CARD

MY CREDIT CARD # IS ____________________________

MASTER[__]CARD[__]VISA OTHER __________________

EXPIRES [_ _ / _ _]

Smoking [___]Non-Smoking [___]Handicapped [___]

Remarks:_______________________________________________________