Deep Physical Agents Modality Course Registration WHEN November 14, 15, and 16, 2008 WHERE: T J Samson Educational Resource Center 922 Happy Valley Road Glasgow, KY 42141

PERSONAL INFORMATION

Last Name:      First Name:

  Address:

     City:     State:      Zip:

Contact Phone:

E-Mail Address:
(Conference confirmation will be sent to this email)

Organization/Facility:

COST:
$250 (KOTA membership required)

PAYMENT INFORMATION

Registration Fee:	$ 250.00
Total Amount to Charge:	$

(MasterCard or Visa accepted)

Cardholder Name:

Card Number:

Expiration Date (month/year):

Billing Address is same as Above

Address:

     City:     State:     Zip:

Conference Hotel: Drury Inn and Suites; Reservations: 270-443-3313 ; say KOTA for conference rate $77 (does not include taxes).
To reserve online, go to www.druryhotels.com, click on Book it Fast, then enter group number 2036418 or call 1-800-325-0720 to make your individual group reservations. Please specify the Hotel location and reference your Group Name.

There are no charges to attend the annual business meeting and the auction. Checks should be made out to KOTA. *KOTA offers reciprocity for members in other State associations to attend the Conference at member rates; Presenters get a 10% discount for conference; No shared registration; or substitutions. Cancellations must be submitted in writing; $25.00 charge for cancellations; Questions: call KOTA at 1.888.987.5682, or email: rhondatedwards@prodigy.net; register online at www.kotaweb.org.