Name: _______________________________Title: ___________________

Nickname for Badge: ___________________________________________

Company/Facility: _____________________________________________

Mailing Address: ______________________________________________

City: ________________________State: __________Zip Code: _________

Telephone: __________________________FAX:____________________

E-mail Address: _______________________________________________

□  Please check here if you require special assistance (attach description of needs).

Fall Seminar Fees:  CMSA Member   $135.00    Non-member  $185.00

CCM Prep Class Fees:  CMSA Member   $135.00    Non-member  $185.00

Attending Both Days:  CMSA Member   $200.00    Non-member    $300.00

Check appropriate boxes below

$___________payment enclosed (make check payable to:  E & I Management, Inc.

Charge $________to my credit card:  ___MasterCard    ___VISA    ___AMEX

Card Number: ___________________________Expiration Date:______________

Name as it appears on the card:________________________________________

Signature: ________________________________________________________

Mail or FAX registration form and payment to:  E & I Management, Inc. 6132 Wild Cherry

Lane, Oxford, NC 27565 or call (800) 318-4408 or FAX (919) 603-6972.  Cancellations

received in writing before October 1st will receive a full refund minus a $25 administrative charge.