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Illinois Music Education Conference 2012 Preregistration


January 25-28, 2012


If submitting by mail, this form and payment must be post- marked no later than January 6, 2012. If submitting by fax (309.677.3321), this form and payment must be sent no later than January 20, 2012.


Name __________________________________________________________________________


School/Organization Name __________________________________________________________________________ Preferred Address __________________________________________________________________________ City _______________________________________


State ______


Preferred Telephone _______________________________________ Preferred Email Address _______________________________________


This a: Home Address Business Address


NAfME Membership # _______________________________________ Expiration Date ____________________ New Member Application/Membership Renewal


must be submitted to NAfME prior to 12/14/2011 for Member/Retired/Collegiate Rates. Current Expiration Date must be later than 12/2011.


Registration Category Please Check Only One


IMEA Member* Non-Member


ICMEA Member*†


College Non-Member† Retired Member*


FEE $76


$226 $26 $40


Free


Primary Teaching Specialization Please Check Only One


Band


Chorus Jazz


Junior HIgh/Elementary Music Music Teacher Education Orchestra


Secondary General Music *NAfME Members MUST include ID# and expiration date above.


†Collegiate Member/Non-Member is identifi ed as a full-time student in a college or university. Payment


If paying with cash, check, or credit card, this form may be submitted by mail (See address information below). If paying with a credit card, this form may also be submitted by mail or fax (Fax Number: 309.677.3321). Your credit card statement will refl ect this charge as Bradley University.


Type of Payment (Check One) Cash Credit Card (Circle One)


Check (Payable to Bradley University–See Address Below) AE


Visa MasterCard Discover Credit Card # ____________________________________ Exp. Date __________ CVC # ___________


Name on Credit Card __________________________________________________________________________ Signature __________________________________________________________________________ Billing Address __________________________________________________________________________ State ______


(if diff erent from above) City _______________________________________


Purchase orders will not be accepted. No refunds will be granted after February 3, 2012.


Check Infomation–If paying by check, make check payable to Bradley University and mail with this completed form to: Bradley University Continuing Education


Attn: IMEC Registration 1501 W. Bradley Avenue Peoria, IL 61625


32 Questions?


Contact Debbie Devine at 309.677.2820 or


devine@bradley.edu


For Offi ce Use Only Membership Verifi cation


Date Received ________ Illinois Music Educator | Volume 72 Number 1


Zip _______________


Zip _______________


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