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Trade Show Attendee Registration

2010/11 IISA Card Number:

REGISTRATION FORM CANNOT BE PROCESSED IF FIELDS BELOW ARE BLANK
First Name:
Last Name:
Title:
Company:
Address:
City:
State:
Zipcode:
Country:
Phone:
Fax:
Email:
AFFILIATION MEMBER TYPES & FEES
  Carnival (Owner/Mgr.)
  Independent Ride (Owner/Mgr)
  Amusement Park (Owner/Mgr.)
  Water Park (Owner/Mgr.)
  Supplier (Owner/Mgr.)
  Circus (Owner/Mgr.)
  Game Concessions (Owner/Mgr.)
  Food Concessions (Owner/Mgr.)
  Straight Sales (Owner/Mgr.)
  Arcade (Owner/Mgr.)
  State Official
  Fair Management
  State Ride Inspector
  Retired
  Other 		  IISA ($0.00)
  IAAPA ($25.00)
  Miami Showmen's ($25.00)
  OABA ($25.00)
  SLA ($25.00)
  GTSA ($25.00)
  Other Organization ($25.00)
  Non Member ($50.00)
If your spouse is planning on attending, please complete this form and submit another for your spouse.

FILL IN ONLY IF THE FOLLOWING ARE ATTENDING

Children under 17 years:  Child #1:
First Name:
Last Name:
Age:
Child #2:
First Name:
Last Name:
Age:
Child #3:
First Name:
Last Name:
Age:
Child #4:
First Name:
Last Name:
Age:
Child #5:
First Name:
Last Name:
Age:

PAYMENT - REQUIRED
Total:
Payment:   Member (no payment)
  Money Order or Cashiers Check by mail
  Credit Card (we will contact you for payment information)
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Larry Nieukirk

Larry Lieukirk

Check out what President Larry Nieukirk has planned for his 2010 Presidency!
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International Independent Showmen's Association

IISA

6915 Riverview Drive
Riverview, FL 33578

Ph: 813.677.3590
Fx: 813. 677.1041
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IISA News

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