Academy Registration

1. Contact Information:

First Name Required Question

Last Name

Title

Company Name Required Question

Street Address Required Question

Apt/Suite/Office

City

State

Postal Code Required Question

Email Address Required Question

Phone Number Required Question

Fax Number

Mobile Phone

Payment is due by March 15, 2012. Registrations without payment will be cancelled at that time.

Payments are due to:
AMTEC
Attn: Melody Traugott
300 N. Main
Versailles, KY 40383

**Please note, if you are paying by credit card you will be required to submit a signed and completed credit card authorization form. This form will be sent to the email that you submit with your registration. Please follow the instructions on the form and return the authorization to Melody Traugott..

If you have a promo code for registration, please proceed to question 3.

2. How will you be paying?

3. Please enter a promo code, if applicable:

4. What, if any, are your dietary restrictions?