APCA 2012 Membership
and Conference Registration

Hershey, PA

School Name:

_________________________________

 School Advisor:

_________________________________

School Address:

_________________________________

City:

_________________________________

State:

__________________    Zip: ______________

Phone:

___________________  Fax: ______________

 Email:

_________________________________

Co-op Buyer:

_________________________________

Would you like to be added to the ListServe? Yes_____ No______

Student Population

Demographics

   __ BELOW 3,000

Public:__  Private:__ 

   __ 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: ____%

Student Activities Journal Subscriptions (3 per membership, extra subscriptions $29.95 per year) should go to:

Name:

________________________________

Address:

________________________________

City:

________________ State: ________   Zip: ________

Name:

________________________________

Address:

________________________________

City:

________________ State: ________ Zip: ________

Name:

________________________________

Address:

________________________________

City:

________________ State: ________ Zip: ________

Names of Delegates Attending APCA
Northeast 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!!

Northeast Programming Conference Pricing

Prior to 2/24/12

Member

Non-Member

Day Pass (member)

Day Pass
(Non Member)

1-5 delegates

$199 / delegate

$239 / delegate

$119 / delegate

$149 / delegate

6+ delegates

$179 / delegate

$229 / delegate

$119 / delegate

$149 / delegate

After 2/24/12

Member

Non-Member

Day Pass (member)

Day Pass
(Non Member)

1-5 delegates

$229 / delegate

$269 / delegate

$129 / delegate

$149 / delegate

6+ delegates

$209 / delegate

$259 / delegate

$129 / delegate

$149 / delegate

Please provide __ Campus membership @ $299 per campus annually.
Total Membership fees enclosed ($299 annually)......................................
 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 numbers on far right, back of card)

Signature: __________________________________ Date:___/___/___

# Vegetarian Meals:_____   # Vegan Meals:_____    
# kosher Meals:____        #Non Dairy Meals:_____

Faculty Advisor    ______________________________                        Date ____________________

Delegation Leader / Co-Op Buyer ________________________________
 

CLICK HERE FOR TRAVEL & LODGING INFORMATION

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