NOTE! - Please use one form per registrant. Complete all sections. Completed forms must be received by NAAG no later than September 23, 2011 in order to receive the reduced registration fee. An asterisk (*) indicates a required field.

Name*: (as it should appear on badge)
Full Mailing Address:
Title:
Phone*:
Fax:
Billing Address: (if different)
E-mail*:
Name: (Person Completing Form)
Phone: (Person Completing Form)
Arrival Information (Meeting ID:1110_BANKR)
Date of Arrival:	Time:
Date of Departure:	Time:
Confirmed your hotel reservations yet? Yes No
Hotel Dates:
Any Dietary Restrictions?
I Am Generally Interested In Attending: (check all that apply, see Agenda for topic listings)
	Tax Breakouts                Beginners Breakouts
	Regulators Breakouts     Advanced Breakouts
State Bar Registration Number(s) For CLE Credit:
	State:   Number:
	State:   Number:
	State:   Number:
Registration Fees (choose one)
	Early Registration: $475.00 (on or before August 20, 2010)
	Regular Registration: $525.00 (after August 20, 2010 )
	Discounted Group Registration $375.00/$425.00 (early/late registration)
	NAGTRI Scholarship Registrant – Fee Waived
	I wish to purchase   additional guest tickets for the Sunday reception and breaks at $50 per person.
Payment (choose one)
	I will mail my check or purchase voucher, payable to “NAAG” , [Federal Tax ID No. 52-1322260]
	Will Pay at Meeting (credit cards accepted)
	Pay by credit card now (complete Billing Information below)
Billing Information (You will receive an email receipt once your payment is processed)
Card Type:	Visa     - or -      MasterCard
Name on Card:
Company (optional):
Street Address:
City:
State:
Zip:
Phone:
Email:
Cedit Card Number:
Expiry Date:	--Month-- January (01) February (02) March (03) April (04) May (05) June (06) July (07) August (08) September (09) October (10) November (11) December (12) / --Year-- 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022
Security Code:
Comments:

Special Requests - If you require any special services or auxiliary aids to assist you while attending the conference, such as sign-language interpreters, note takers, large print materials or Braille materials, please advise us when making your reservation.  NAAG will work with you in making suitable arrangements to enable you to participate.
 
*This is the address we will list for you in the NAAG database, and will update any existing listing for you, unless you advise us otherwise.  If you want to use another address for general mailings, please attach a note, so indicating.

By submitting this form I authorize NAAG to charge
my credit card for the above listed items & services.