Attendee Name:

U.S. House Representative(s):

(Find your Representative)

Company:

Email Address:

Work Address:

City:

State / Zip:

Home Address:

City:

State / Zip:

Cell Phone:

Work Phone:

It is very important that we have all the above information so NAMIC can make certain that we try to capture a constituent from EVERY district within the state. It's easier to get the Congressperson's attention when their constituent will be involved in the meeting.

Please answer the following brief questions:

Room preference: Non-smoking     Smoking

Number of rooms required:     Number of guests per room:

Arrival Date    Departure Date

Check the nights you require a hotel room:
Friday   Saturday   Sunday   Monday   Tuesday   Wednesday

Other special instructions:

Register online by March 17, 2010

NAMIC will make all hotel room reservations.