Illinois Self-Insurers Association

Complete this form to register for the 2009 Annual Meeting

First Name:

Last Name:

Title:

Company:

Address:

City:

State:

Zip Code:

Office Phone:

Mobile Phone:

Email Address:

Planning on attending the barbeque dinner on Thursday, October 1st?:
Yes
No

Interested in golfing on Wednesday, September 30th?:
Yes
No

Select Appropriate Fee:

Comments:
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