Quarterly Meeting and CE Registration

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AMTA AL Chapter Fall Quarterly Meeting and CE Online Registration

AMTA – AL CHAPTER

Fall Quarterly Meeting and CE

Virginia College

436 Palisades Blvd

Birmingham, AL

To reserve your place at the AMTA AL Chapter Fall Quarterly Meeting and CE please complete all information and send the form below electronically
by clicking the Submit Registration button at the bottom.

If you choose to pay by check please make your check payable to AMTA-AL Chapter
and mail your payment with your registration form to, AMTA-AL Chapter, c/o Joseph Bright, Program/Clinic Director Therapeutic Massage Virginia College, 2800 A Bob Wallace Ave, Huntsville, AL 35805, E-mail

Please call 256-338-3062 or 888-672-5273 if you have questions.

If you are registering after November 1, 2005, please do not mail payment. Complete the electronic form and you may pay by credit card,
or bring your check or cash payment with you to the meeting.
Please still fill out your choices on the form so we have them for planning purposes.

Please complete all the information requested.
Choose your response for each drop down menu below to reserve space or indicate you will not attend a given session or event.
Complete your electronic registration by clicking ONCE on the Submit Registration Button.,

Name:
Address:
City:
State:	Zip Code:
Email:
Phone Number:	Work Number:
AL LMT Number	AMTA Member Number:
Comments:
Registration / Participation Option:
Method of PaymentOption:
Type of Credit CardOption:
Credit Card Number:
Expiration Date:
Name On Card:
I Authorize This TransactionOption:

Thank you for your registration,
we look forward to your participation with the AMTA-AL Chapter.
SEE YOU AT THAI ON THE TABLE AT VIRGINIA COLLEGE, BIRMINGHAM!