AICP Great Lakes Chapter by 04t6jy


									                                    AICP Great Lakes Chapter
                                       E-Day - April 15, 2011
                      REGISTRATION FORM – For New AICP Members
                      (Use this form ONLY if you are applying for AICP membership and
                         Registering for the Great Lakes E-Day CONCURRENTLY)

                                                                                           Are you joining us
     Please feel free to make copies of this registration form and encourage
                                                                                           Thursday evening
                                others to attend!                                            (April 14th)?
Registrant’s Name:                                                                              Yes /     No
Registrant’s Name:                                                                              Yes /     No
Registrant’s Name:                                                                              Yes /     No
E-mail Address:
Telephone Number:
Line of Business:                  Property and Casualty                 Life/Health               Both

Special Needs: Please indicate any special dietary or ADA needs:
          New Member: A check for        Industry ($190) or      Regulator ($50) is enclosed.
To take advantage of this special offer, please complete this registration form and the
 AICP membership application (to the right). Submit both with a separate registration           AICP Membership
     fee. Registration must be postmarked, faxed or e mailed by April 7, 2011.                     Application

All checks should be made payable to the AICP and sent to Jim Morgan at the address below. Please
return the completed registration form, the appropriate registration fee, and any panel
discussion questions no later than April 7, 2011 to:
               Jim Morgan
               HDI-Gerling America Insurance Company
               150 N. Wacker Drive, 29th Floor
               Chicago, IL 60606
If you have any questions, please contact Jim at (312) 456-6779, fax number (312) 924-0926, or
by e-mail at

Registration may be submitted by credit card; please provide the following information and fax or e-mail
to Jim Morgan:
Credit Card Type:        VISA     MASTERCARD          AMERICAN EXPRESS          Registration Fee $
Card Number:                                               Expiration:

Name As It Appears on Card:

SIGNATURE:                                                                             DATE:

  If you have a question(s) that you would like to submit for a particular session, please indicate the
                   question below and indicate the session/speaker it pertains to:
1. Session:
2.     Session:

                      (If more room is needed for questions, please attach separate page)

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