APCA 2012 Membership
and Vegas Registration
LAS VEGAS, NV
Delegate fees are non refundable, but a $75 credit per cancelled delegate towards your choice of another APCA conference is allowable in event of cancellations (good for one year from ending date of canceled conference).

School Name:

_______________________________________  Date: ____________

 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
(list additional delegates separately):
Circle Yes or No (Y or N) as to whether the delegate is a Certification Candidate.

 

 

Delegate 1 _______________________

Yes

No

 

Delegate 9 ________________________

Yes

No

Delegate 2 _______________________

Yes

No

 

Delegate 10 _______________________

Yes

No

Delegate 3 _______________________

Yes

No

 

Delegate 11 _______________________

Yes

No

Delegate 4 _______________________

Yes

No

 

Delegate 12 _______________________

Yes

No

Delegate 5 _______________________

Yes

No

 

Delegate 13 _______________________

Yes

No

Delegate 6 _______________________

Yes

No

 

Delegate 14 _______________________

Yes

No

Delegate 7 _______________________

Yes

No

 

Delegate 15 _______________________

Yes

No

Delegate 8 _______________________

Yes

No

 

Delegate 16 _______________________

Yes

No

List each # of t-shirt sizes required for certification candidates: 
___ SM     ___M    ___ LG    ___ XL    ___ XXL   ___XXXL
 

DELEGATE LISTING:
List names of APCA Certification course candidates below. All Certification fees are included in your delegate fees.

Delgate Name: ______________________ D.O.B:_______________
Degrees Held: _________________________________________________________________
Current Institution: _____________________________________________________________
Phone: ________________________ Desired Certification Course:____________________________

Delgate Name: ______________________ D.O.B:_______________
Degrees Held: _________________________________________________________________
Current Institution: _____________________________________________________________
Phone: ________________________ Desired Certification Course:____________________________

Delgate Name: ______________________ D.O.B:_______________
Degrees Held: _________________________________________________________________
Current Institution: _____________________________________________________________
Phone: ________________________ Desired Certification Course:____________________________

Delgate Name: ______________________ D.O.B:_______________
Degrees Held: _________________________________________________________________
Current Institution: _____________________________________________________________
Phone: ________________________ Desired Certification Course:____________________________

MEALS:
# Vegetarian Meals:____    #Kosher Meals:___ 

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

Las Vegas, NV Institute Pricing

Prior to 12/3/10

Member

Non-Member

Member Day Pass

Non-Member Day Pass

1-5 delegates

$299 / delegate

$369 / delegate

$179 / delegate

$199 / delegate

4-8 delegates

$279 / delegate

$349 / delegate

$169 / delegate

$189 / delegate

9+ delegates

$259 / delegate

$339 / delegate

$149 / delegate

$179 / delegate

After 12/3/10

Member

Non-Member

Member Day Pass

Non-Member Day Pass

1-5 delegates

$349 / delegate

$389 / delegate

$199 / delegate

$229 / delegate

4-8 delegates

$329 / delegate

$369 / delegate

$189 / delegate

$219 / delegate

9+ delegates

$309 / delegate

$349 / delegate

$179 / delegate

$209 / delegate

Campus membership fees enclosed ($199 annually)
Number of memberships you're paying for: _____ or
     ___ I am already a member in good standing
Schools registering delegates must be APCA members in good standing or pay nonmember prices.

$_________

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

$_________

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 LAS VEGAS TRAVEL & LODGING INFORMATION

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

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