2007 IEMTA CONFERENCE REGISTRATION

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" colspan=2 height=90 BGCOLOR="#006699" TEXT="#080000" background="063085a3.jpg"> <div> <FONT SIZE="6" COLOR="#FFCC33" FACE="Arial" ><B>   Illinois EMT Association</B></FONT><B>    </B><B> |     </B><A HREF="index.htm" TARGET="_top" TITLE=" Illinois EMT Association"><U><B>Home</B></U></A></div> <bR> <DIV ALIGN="LEFT"></DIV> <div> </div> </td> </tr><tr> <td valign="top" width=210 BGCOLOR="#FFFFFF" TEXT="#080000" background="064d2e83.jpg"> <div> <IMG SRC="067b73c0.jpg" border=0 width="183" height="60" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <bR> <div> <B><U>BOARD OF DIRECTORS</U></B></div> <div> <B>Augie Bamonti</B></div> <div> <I><B>President</B></I></div> <div> <B>Tina Meadows</B></div> <div> <I><B>Vice President</B></I></div> <div> <B>Gene Ryan</B></div> <div> <I><B>Secretary</B></I></div> <div> <B>Alan Davis</B></div> <div> <I><B>Treasurer</B></I></div> <bR> <div> <B>Pamela Davis</B></div> <div> <B>Colleen Evans</B></div> <div> <B>Vicki Gallaher</B></div> <div> <B>Bret Jefferies</B></div> <div> <B>Joni Ann Jones</B></div> <div> <B>Rodney Porteus</B></div> <div> <B>Paul Rasch, Jr.</B></div> <div> <B>Susan Schlebach</B></div> <div> <B>Michael Weaver</B></div> <bR> <div> <B><U>NAEMT GOVERNOR</U></B></div> <div> <B>Augie Bamonti</B></div> <bR> <div> <B><U>LEGAL COUNSEL</U></B></div> <div> <B>Atty. William King</B></div> <bR> <div> <B><U>WEBMASTER</U></B></div> <div> <B>Paul Rasch, Jr.</B></div> </td> <td valign="top" height=390 BGCOLOR="#FFFFFF" TEXT="#080000" background="06507073.jpg"> <div> <IMG SRC="068a38f0.jpg" border=0 width="419" height="143" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> <B><U>2007 IEMTA CONFERENCE REGISTRATION</U></B></div> <div> <B>(PLEASE PRINT LEGIBLY)</B></div> <bR> <bR> <div> <B>NAME:________________________________________________________________________________________________</B></div> <bR> <bR> <bR> <div> <B>ADDRESS:_____________________________________________________________________________________________</B></div> <bR> <bR> <bR> <div> <B>CITY, STATE, ZIP CODE:__________________________________________________________________________________</B></div> <bR> <bR> <bR> <div> <B>COUNTY:______________________________________________________________________________________________</B></div> <bR> <bR> <bR> <div> <B>EMAIL ADDRESS:______________________________________________________________________________________</B></div> <bR> <bR> <bR> <div> <B>HOME PHONE NUMBER:____________________________    WORK PHONE NUMBER:_____________________________</B></div> <bR> <bR> <bR> <div> <B> AGENCY AFFILIATION:___________________________________________________________________________________</B></div> <bR> <bR> <bR> <div> <B>RESOURCE HOSPITAL:__________________________________________________________________________________</B></div> <bR> <bR> <div> <B><U>Conference Registration Fee</U></B></div> <bR> <div> <B>Members - $ 80.00</B></div> <div> <B>Non-Members - $100.00</B></div> <bR> <div> <B><U>Make checks payable to ILLINOIS EMT ASSOCIATION</U></B></div> <div> <B><U>and mail along with application to:</U></B></div> <bR> <div> <B>Tina Meadows</B></div> <div> <B>102 Mockingbird Lane</B></div> <div> <B>Leroy, Illinois, 61752</B></div> <bR> <div> <I><B><U>For additional conference information contact Tina at 309.962.3811</U></B></I></div> <bR> <div> <I><B><U>For room reservations contact the Northfield Inn at 217.523.7900</U></B></I></div> </td> </tr></table></body>