APCA 2011 Membership
and Conference Registration
SYRACUSE, NY

School Name:

_________________________________

 School Advisor:

_________________________________

School Address:

_________________________________

City:

_________________________________

State:

__________________    Zip: ______________

Phone:

___________________  Fax: ______________

 Email:

_________________________________

Student Population

Demographics

   __ BELOW 3,000

Public:__  Private:__  Religious Affiliated:____

   __ 3,000 – 5000

Commuter: __

   __ 5,000 - 10,000

4-year: __ 2-year: __

   __ 10,000 -15,000

Tech/Trade: __

   __ 15,000 - UP

Activities Budget: $ __________

% of Budget spent on:

Comedy: ____%

Lectures: ____%

Movies: ____%

 

Music: ____%

Novelties: ____%

Other: ____%

Names of Delegates Attending APCA Fall Programming Conference
(list additional delegates separately):

Delegate   1 _______________________

Delegate   9 _______________________

Delegate   2 _______________________

Delegate   10 _______________________

Delegate   3 _______________________

Delegate   11 _______________________

Delegate   4 _______________________

Delegate   12 _______________________

Delegate   5 _______________________

Delegate   13 _______________________

Delegate   6 _______________________

Delegate   14 _______________________

Delegate   7 _______________________

Delegate   15 _______________________

Delegate   8 _______________________

Delegate   16 _______________________

All schools registering delegates must be APCA members in good standing or pay non member prices.
REGISTER EARLY AND SAVE BIG!!

Syracuse, NY Conference Pricing

Prior to 9/7/11

Member

Non-Member

Member Day Pass

Non-Member Day Pass

1-5 delegates

$189 / delegate

$219 / delegate

$109 / delegate

$149 / delegate

6+ delegates

$169 / delegate

$199 / delegate

$109 / delegate

$149 / delegate

After 9/7/11

Member

Non-Member

Member Day Pass

Non-Member Day Pass

1-5 delegates

$219 / delegate

$259 / delegate

$139 / delegate

$169 / delegate

6+ delegates

$199 / delegate

$239 / delegate

$139 / delegate

$169 / delegate

Military Programmers Receive 20% Off Delegate Fees

__ Campus membership fees enclosed ($299 annually) - number of memberships:_____
     ___ I am already a member in good standing
Schools registering delegates must be APCA members in good standing or pay nonmember prices.

$_________

Total # of Shirts:______

Indicate # per size:
____ SM  ____ Med   ____ Lg  ____ XL  ____ XXL   ____ XXXL

$_________

TOTAL FEES ENCLOSED or AUTHORIZED TO BE CHARGED
The APCA FEI Number is 650551461

$_________

# Vegetarian Meals:____   

Credit Card Orders:
__VISA   __MasterCard  __American Express
Card Number: ________________   Exp. Date: ________
Name on Card: ________________________
CVV2#: ______ (3 digit # on right back or card)
 
Signature: __________________________________ Date:___/___/___

Billing Information:
Billing Address:______________________________
City, State: _________________, _________ Zip: _____________

Faculty Advisor    ______________________________                        Date ____________________

Delegation Leader / Co-Op Buyer ________________________________
 

Fax to:
(865) 908-7104
or
Mail to:
APCA
PO Box 4340
Sevierville, TN 37862

Questions???? Call (800) 681-5031