Early Bird Deadline: 

Hotel:  Make your personal reservations directly with Grand Hotel Marriott Resort, Golf Club & SPA at  800-544-9933, group code:  NAIFA MS-AL 

(Hotel Rate is $179/night and the hotel deadline is                           ).

Registration Form:  Please Print or Type

____________________________________________________________________________________________________________
First Name                              Last Name                                                Nickname for Badge

Designations (Circle)
LUTCF, CLU, ChFC, CFP, CPCU, FLMI, FSS, RHU, CLF, AMTC, Other _______________

Local Association Name_________________________________________________________________________________

~~Company and/or Firm   ________________________________________________________________________________________________

___________________________________________________ _____________________________________________
Office Address                                                              City                   State                    ZIP

_______________________________________________ ____________________________________________________________
 Phone (Office)                                                       E-mail Address

Circle all of the following that are current:  NAIFA-MS Foundation, NQA, NSAA, NMSA, HSQS, MDRT

IFAPAC contributor Level: (please circle): 
Annual:  Investor, Century Club, Ambassador, Statesman, Envoy, Diplomat, Emissary, Capitol

       CE FOR THE CONVENTION:  Will include Monday 8:00 a...m. to 12:00 noon and CE 1:45 p.m. to 4:45 p.m.
                                                         Tuesday morning from 8:00 a.m. to 12:00 noon for a total of 10 hours of CE.
 
/__/   Check if you need Continuing Education Credits

====================================================================================================

If this is a double registration (NAIFA Member/Spouse or Member/Guest) ___ Yes ___ No

_______________________________________________________    ____________________________________________________
Spouse or Guest Name                                                                 Nickname for Badge

~~Guest Registration: Fee required if guest is 17 or older. Anyone in the insurance business is required to pay the full 
                                       Registration fee.

Name Tags for children ________________________________________ age __________

_____________________________________________- age _________, ______________________________ age _____________

     We must have an accurate count for the noon Monday Awards Banquet,  Pizza Party and 
     Tuesday's Breakfast.      PLEASE CONFIRM ATTENDANCE:
/__/ Yes, # of attendees for Banquet _____     /__/ Kids Pizza Lunch _____     /__/ Tuesday Breakfast _____
 

                                                   2014 CONVENTION REGISTRATION FEES

Registration and Payment Policy:  Please send payment with registration form.
                                                         Registration will not be processed until payment is received.

Cancellation Policy: All cancellations must be in writing to the NAIFA-MS office. Cancellations after 
                                   May 27th, will be charged a processing fee of $75.00.

Fees include – Opening Night Event, Meetings, Banquet & Tuesday breadfast (Golf Tournament is separate)

• Double Registration includes admission for two to above functions. (NAIFA Member/Spouse or
                                                                                                                                          Member/Guest)
• Single Registration includes admission for one to above functions.

MEMBERSHIP REGISTRATION FEES                                QUANITY     COST           SUBTOTAL

Double Registration before May 22   (Early Bird Rate      __________     $250.00         _____________

Double Registration after May 22                                     ___________    $265.00         _____________

Single Registration before May 22  (Early Bird Rate       ___________     $230.00         _____________ 

Single Registration after May 22                                      ___________     $245.00         _____________

NON-MEMBERS:
You must register above & pay above fees plus $60.00 for CE Credits  ______  $60.00   __________

6/22/14  Golf Tournament (Includes green fee and carts)        __________        $80.00         ______________
Additional Banquet Tickets                                               ___________       $50.00         ______________
Additional Opening Night Evet Tickets                             ___________       $50.00        ______________

GRAND TOTAL                                                                   Total Amount Enclosed      $_____________

                                                                 MAKE CHECKS PAYABLE TO:  NAIFA MS

                                                                 Remit Check Payment and Completed Form to:

                                                                                           NAIFA-Mississippi
                                                                                           P. O. Box 13649
                                                                                      Jackson, MS  39236-3649
If Paying by Credit Card, please FAX or EMAIL Completed Form to:

E-mail:  NAIFA-Jackson@comcast.net      Fax:  (601) 981-2745

CREDIT CARD PAYMENTS ACCEPTED

Credit Card Type _______________________        Credit Card Number _______________________________________

Security Code _________________________         Expires _____________________  Zip Code ____________________

Signature ___________________________________________            Amount to Charge  $_______________________

Amount will be charged plus a 3% Credit Card Processing Fee.

ANY QUESTIONS OR ADDITIONAL INFORMATION:    Contact:  Fonda Devrow           Phone:  (601) 981-1522