Registration form for the 2013 Virginia Council Meeting. A fillable PDF, please type into the form, then print and mail with your registration check.

1. 27th
Annual Virginia State Council Meeting
“Tomorrow’s Opportunity Starts Today”
October 19, 2013
CRAFT COLLISION CENTER – CLASSROOM
1804 Graves Mill Road; Lynchburg, VA 24502
Please print or type and do not use abbreviations (except for designations).
Information will be printed in the program as it appears below.
Name: __________________________________ Name on Badge: _____________________________
Designations: __________________________________________________________________________
Preferred Address: ______________________________________________________________________
Association Name (or Member at Large):_____________________________________________________
Employer Name: ________________________________________________________________________
Telephone: _________________________ Fax Number: _________________________
Email Address: _________________________________________________________________________
**If you would like your e-mail address included in the program, please check here: ___________________
Please circle all that apply:
National Officer Past National Officer Past State Director Past RVP CWC Contestant
First Timer Founders Circle Local President CPIW/CPIM DAE
Delegate Alternate
Registration Fees – Includes All Meals and classes
Member Registration $ 30.00 Late Registration Member $ 40.00 (after 9/30)
Non-member Registration $ 40.00 Late Registration Non-member $ 50.00 (after 9/30)
TOTAL FOR REGISTRATION: $______________
“PLEASE ADVISE OF ANY DIETARY RESTRICTIONS, PLEASE BE SPECIFIC”
_______________________________________________________________________________________
Registration Deadline Postmarked is September 30, 2013. No Refunds after October 9, 2013.
Make checks payable to: VIRGINIA COUNCIL of IAIP Federal Tax ID: Virginia Council of IAIP FEIN #541581198
Mail to: Annette Ardler 100 Linden Street, #C Ashland, VA 23005
Hotel information: Due to a football game at Liberty University on the day of our meeting, hotel room space is a little tight and we do not
have a set block of rooms available. Here is a recommendation to call if you need a room: Hampton Inn Lynchburg, 5604 Seminole
Avenue, Lynchburg, VA 24502; 1-434-237-2704.
If unable to attend the Council Meeting in person, we do have some availability to Skype you in! Please
complete the registration form above and return it to Annette Ardler (without payment) by October 4,
2013. Instructions will be emailed to you. Your information will be included in the Conference Program.