2009 IEMTA CONFERENCE REGISTRATION

(PLEASE PRINT LEGIBLY)

NAME:________________________________________________________________________________________________

ADDRESS:_____________________________________________________________________________________________

CITY, STATE, ZIP CODE:__________________________________________________________________________________

COUNTY:______________________________________________________________________________________________

EMAIL ADDRESS:______________________________________________________________________________________

HOME PHONE NUMBER:____________________________    WORK PHONE NUMBER:_____________________________

 AGENCY AFFILIATION:___________________________________________________________________________________

RESOURCE HOSPITAL:__________________________________________________________________________________

Conference Registration Fee

Members - To Be Determined

Non-Members - To Be Determined

Make checks payable to ILLINOIS EMT ASSOCIATION

and mail along with application to:

Tina Meadows

102 Mockingbird Lane

Leroy, Illinois, 61752

For additional conference information contact Tina at 309.962.3811

For room reservations contact the Northfield Inn at 217.523.7900