nickname (for badge)  

title  

company  

city / state / zip code*  

phone*  

e-mail*  

Please describe any Dietary or   
Accessibility Needs, if applicable:  

CE/CLE CREDITS

I would like to receive PA Insurance Licensing CE Credits for this seminar.
  Producer License Number: (for reporting of CE Credits)

I would like to receive PA CLE (Legal) Credits for this seminar.

 

RECEPTION

I will be attending the Wednesday evening Reception & Exhibit Show.

PLEASE SELECT FROM THE FOLLOWING OPTIONS

Two Days          PAMIC Member/Associate: $250     Non-Member: $325
Single Day        PAMIC Member/Associate: $150     Non-Member: $225

If only attending one day, please specify which day you will be attending:
Wednesday, April 2        Thursday, April 3

TOTAL DUE

Please Note: The two-day price is only available for a single individual attending both days. It cannot be split between two different people.

 

PAYMENT OPTIONS

Will Send Check
Please Send Invoice
Pay Online using Paypal (Click on the Paypal link after hitting Submit.)*
* There is a $5 surcharge to use this service.