Fall printable

APCA 2011 Membership
and Fall Conference Registration

Coralville, IA

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!!


	*Conference Pricing*

Prior to 9/28/11	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 9/28/11	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
Spousal Fee	$129

__ 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:____ # Vegan Meals:___ #Kosher Meals:___ # Non Dairy 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 ________________________________

	Click Here for Travel & Lodging Information DO NOT SEND MONEY TO APCA! The Fax to (865) 908-7104 or mail to: APCA - PO Box 4340 - Sevierville, TN 37862 Questions???? Call (800) 681-5031 or visit www.apca.com