2012 National REIA Educational Cruise

Passenger #1

Names on Passport:

Dates of Birth (mm/dd/yyyy):

Names Desired on Name Tags:

Name of Your Real Estate Investor Group:

Passenger #2

Names on Passport:

Dates of Birth (mm/dd/yyyy):

Names Desired on Name Tags:

Name of Your Real Estate Investor Group:

Passenger #3

Names on Passport:

Dates of Birth (mm/dd/yyyy):

Names Desired on Name Tags:

Mailing Address:*

Street AddressCityStateZip Code

Phone:

Emergency Phone:

Fax:

Email:*

(Must use real email addresss or you will get an error on submitting)

I am member of

Board Member

Position

Would you like to moderate a Q&A session?

Yes, on the following topic:
No.

Yes, on the following topic:

Please select your dinner preference:

Main Dinner
Late Dinner (will miss cocktail parties and Q&A sessions)

Please select one room preference:

Inside Cabin
Window Cabin (+$150 p/p)
Balcony Cabin (+ $275 p/p)

Do you need a roommate?

Yes, match me with another single.
No.

Do you want to purchase the Insurance Protection Plan (+69 for Inside, $89 for Window, $99 for Balcony)

Yes, please sign me up.
No thanks.

Select if you need the following:

You will need to pick up Bus Transfers at the Airport.

Please select your tee shirt size(s ) (Passenger #1):

If available Shirts can be picked up when you check in.

Please select your tee shirt size(s) (Passenger #2):

If available Shirts can be picked up when you check in.

I would NOT like to receive valuable correspondence from National REIA about legislative alerts, event updates and vendor specials.

Special Requests:

Please select your payment method below:

Your promotional code can be found on your flyer, postcard or the webpage.
If you can not find your promotional code please key 1234

Promotional Code: *

I would like to pay with a credit card. My card number is:*

expiration date (mm/dd/yyyy) is:*

National REIA
525 W. 5th Street Suite 101 Covington KY 41011
Phone: 859-261-3335

2012 Cruise Registration Form