BROCHURE REGISTER

REGISTER

Please fill out the form below to register for the conference

 Personal Information
 Mailing Address
 Registration Options
  Conference Attendee ($1,195 on Or before December 31st, $1,295 after December 31st, $1,495 after March 31st)
 I would Like to register for the Clifton Strengths Sessions
 I would Like to reserve exhibit space ($1,795 on Or before March 31st, $1,895 after March 31st)
 I would Like to be a sponsor
 I am exhibit staff ($0 for first exhibit staff person; $250 for second exhibit staff person)
Please indicate If you'd like CE credit in Texas, Florida or Louisiana. Please include your license number if available.
 Have you received or are you currently working toward a designation from American Educational Institute? Yes No
 Will you require special assistance at this Event (ADA accessibility)? Yes No
 Do you have any food allergies? Yes No
If yes, please name them:
 Will you be attending any of the following events/activities? (separate fees may apply)
 Group Dinner
 Airboat Adventures Tour ($90 fee applies)
 Dinner Jazz Cruise (evening of May 4th) - $90 fee applies
 Dinner Jazz Cruise - No Dinner (evening of May 4th) - $50 fee applies
 AEI Designation Conferment (no additional fee for designees)
 Guest Information (only if applicable)
Guest Name
 I would Like to register my guest for conference meals and receptions (separate guest fee of $175 applies)
Will your guest be attending any Of the following events/activities?
 Group Dinner
 New Orleans School of Cooking ($165 fee applies)
 Airboat Adventures Tour ($90 fee applies)
 Dinner Jazz Cruise (evening of May 4th) - $90 fee applies
 Dinner Jazz Cruise - No Dinner (evening of May 4th) - $50 fee applies
 AEI Designation Conferment (included in $175 guest fee, otherwise $50 fee applies)
 Discount Code / Special Requests
Enter your discount code (if you have one)
Special requests or anything you'd like us to know?
PRESENTED BY:


SPONSORED BY:

INTERNATIONAL INSURANCE INSTITUTE, Inc.
6221 S. Claiborne Ave. Ste. 639
New Orleans, LA 70125
www.InsuranceInstitute.com
Questions? Contact Lisa at 612.868.3650 or lisa@insuranceinstitute.com