First Name:                                                                                                          MI:

Last Name:

AMA # (MUST be a current AMA member to participate):

Frequency Requested:  (Limited to 2 flyers per frequency)

                        Primary Choice?                           Secondary Choice?

T-Shirt Size: (circle one)        L     XL     XXL

Billing Address:

Apt.:

City:                                                                                                         State:

Zip/Postal Code:                                                                       Country:

E-mail Address:

Phone Number:  (     -     -     )     _     _     _     --     _     _     _     _

Registration fee is $30 US and includes both days registration and lunch both days.  If using a check, 

make payable to SASS.

Payment Type:  Visa, Master Card, American Express, Discover, Check, Money Order

       If Using A Credit Card:

                   Credit Card Number:                                                           Expires ( month / year ) :

                   Name (as it appears on card):