Kansas Agents Legislative Day
2015 Registration Form
Agency Name _______________________________________ Contact Person ______________________
Address ____________________________ City ________________ State ________ Zip _____________
Pay one registration fee and bring as many agents from your staff as you wish.
Each attendee from your agency will receive lunch, a steak dinner and 2 ETH/3 GEN hours.
Name of Attendee
Indicate which events each person will attend
Capitol Visits
1 _______________________________
2 _______________________________
3 _______________________________
4 _______________________________
9 a.m. to Noon
q Attending
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Lunch & Program
Steak Dinner
q Attending
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Noon to 5 p.m.
5 p.m.
Payment Options
q Check made payable to “KAIA” is enclosed for $55
q Charge to _________________________________ Exp Date ___________ Security Code ________
Return form to KAIA, 815 SW Topeka Blvd., Topeka, KS 66612 or fax to 785-232-6817
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