August 30-31, 2010 in Sioux Falls, SD

Please print, complete 1 form for each attendee and fax to 605.335.0629

Online Registration available here.

Hotel reservations must be made separately directly through one of the preferred hotels listed here.

Registration Rates Good Through Date of the Event (all registrations include two meals - Monday and Tuesday lunches):

___ Affiliate: $349        ___ Non-affiliate: $449    

___ International: $0  

__________________________________________________________             ____________________________________
First Name                                                                                                   Last Name

__________________________________________________________            ____________________________________
Organization                                                                                               Affiliate ID– Required for Affiliate Registration

____________________________________________________________________________________________________
Address

_______________________________________________________________________________              ______________
City, State, Zip                                                                                                                                   Country

_______________________________________________           ________________________________________________
Phone                                                                                     Fax

______________________________________________________                  ______________________________________
E-mail                                                                                                        Web Site

 Payment Information    * The Abstinence Clearinghouse reserves the right to reject any registration for any reason.

___   Check # _________                                                      

_____ Credit Card (circle one) VI   MC   DS (Sorry no AMX)            Total Amount (Registrant) $ ____________

_________________________________________   __________      ________   ______________________________________
Card Number                                                        V-Code             Exp. Date    Name on Card

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Office Use Only
Payment Processed on:__________ by: _________ RE: ______________ Package Sent: __________ by: _______