ALASKA WATER WELL ASSOCIATION

P. O. Box 113156, Anchorage, AK 99511

MEMBERSHIP APPLICATION & CONFERENCE REGISTRATION

March 4^th and 5^th 2010

Name ________________________________________________________________

Company _____________________________________________________________

Address _______________________________________________________________

City/State/Zip __________________________________________________________

Telephone ________________________________ Fax _________________________

Email _________________________________________________________________

Business License # ___________________Contractor’s License #_________________

Member NGWA _____Yes _____No

Conference Registration - Members - $120.00 $ _________

Additional members from same company - $60.00 $ _________

Non-Members - $150.00 $ _________

One day attendee - $60.00 $ _________

Registration fee includes conference events, continental breakfast and lunch each day

Yearly Dues:

Contractor (corporate) - $125.00 $ _________

Wholesale/manufacturer/supplier (corporate) - $175.00 $ _________

Additional corporate members after initial dues - $25.00 $ _________

Associate (individual) - $50.00 $ _________

Technical (individual) - $20.00 $ _________

Grand Total $ _________

Please complete this form and return it by fax to 907-562-5971. Payment can be sent to the above address or you can bring it to the conference. (We do not accept credit cards) If you have any questions please contact Karen at 907-562-2312.

Hotel reservations should be made directly with the Wedgewood Resort. Mention Group Code

AWWA10 or the Alaska Water Well Association to get our special rate of $70.00 plus tax. Their

number is 1-800-528-4916 or 907-452-1442.

If you have any problems with the hotel, ask for Becky Kunkle