The Agent Resource Center

REGISTRATION FORM

(Print and fax this form to 317-569-9016)

Name: __________________________________________________________ Phone: _____________________

Address: ________________________________________________________ Cell: _______________________

City: __________________________________ State: __________ Zip: ____________

Email: ______________________________________________

I will be attending the VA Aid and Attendance Bootcamp in Indianapolis, IN on September 13th and 14th.

I ___ will ___ will not require a hotel reservation for my stay. Hotel rooms will be booked for the nights of Sunday, September 12th and Monday, September 13th. The room is included in your tuition. Additional nights are available at a reduced rate. If you do not require a hotel room, the tuition is discounted to $500. A credit card may be used to register. If you cancel prior to 7 days before the seminar, a full refund will be made to your account. If you cancel within 7 days of the seminar, a total charge of $250 will be made to your card to offset expenses. You may also pay by company or personal check. Mail to: A2Z Annuity Marketing, 9465 Counselors Row, Suite 102, Indianapolis, IN 46240.

You will be responsible for transportation to and from the hotel. Breakfast, lunch, and dinner will be provided on Monday, September 13th. Breakfast and lunch will be provided on Tuesday, September 14th.

An optional training session with case developement will take place on Wednesday, September 15th. If you plan to attend please do not book a return flight prior to 2:30 p.m. on Wednesday, September 15th to allow ample time to return to the airport. If you plan to travel on Tuesday evening please do not book flights prior to 7:00 p.m. est.

I ___ will ___ will not attend the additional half-day session. I realize I will be billed $150 for the additional half-day which will include an additional night of hotel stay on Tuesday September 14th and breakfast Wednesday morning.

If you have any special requests or dietary restrictions, please note them here: ___________________________________

_________________________________________________________________________________________________

Thank you . . . .

Credit Card Authorization:

Name on card: ______________________________________________________________________

Card Number: ________________________________ Security Code: _____________ Exp. Date: ___________

Signature:____________________________________________________ Date: _________________