NAIFA MT 2023 Annual Conference

Personal Information

• * First Name:
• * Last Name:
• Designations
• * MT Insurance License #
• * National Producer Number Required for CE Credit
• * Email Address:
• * Confirm Email Address:
• * Address 1:
• * City:
• * State: --Choose-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming -------------- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory
• * ZIP Code:
• * Cell Phone:
• Phone:

• Fee

  Type	Fee
  Member	$175.00
  First Time Member Attendee or YAT (Young Advisor age 40 or under or first 5 yrs. in the business)	$150.00
  Non Member ($100 credit towards membership if join before end of convention	$275.00
  Spouse Total Reg. Includes ALL Meals	$75.00
  Spouse IFAPAC Dinner Tues.	$40.00
  Spouse President's Luncheon Wed.	$25.00

Guest Information

You may add a maximum of 5

Special Dietary Needs

• Do you have special dietary needs, of so please specify