REGISTRATION FORM

H.I.S. BUYERS SEMINAR

October 1 & 2, 2008, Las Vegas, Nevada - Harrah's Flamingo Hotel

Please fill out and fax along with a purchase order or credit card number to 815-550-1747, or mail with your check made payable to: HIS Professionals, 29W514 Cerny Circle, Warrenville, IL 60555   For further information, call Dick Schopp at 630-821-7733 . Registrants are liable for the full registration fee. No refunds are permitted unless the seminar is cancelled.

ATTENDEES : Please print names and titles of those attending:

1) Name:______________________________Title:__________________

2) Name:______________________________Title:__________________

3) Name:______________________________Title:__________________

4) Name:______________________________Title:__________________

FEES:  Based on the number of registrants:

Up to 2 @ $295.00 each = $____________

3 or more @ $250.00 each = $ __________

Total = $ __________

CONTACT INFORMATION:

  Name:______________________________Title:__________________

Name of Facility:____________________________   Bed Size _________

Street Address:______________________________________________________

City/State/Zip___________________________________________________

Phone Number____________________ E-mail : ______________________

PYMENT METHOD :

1. Check : Check Enclosed For $_________    (Make check payable to “HIS Professionals”)

2. Purchase Order: PO Number: ____________________  Date_________

Authorized P.O. Signature: ___________________________________________________________

3. Credit Card

Card Type (MC, VISA): ____________________________

Credit Card #: __________________________________

Name on Credit Card: __________________________________

Expiration Date:______________________