Sign me up for CCI’s Annual Statewide Convention
’Real People. Real Power. Real Choice.'
July 18-19 at the Hotel Fort Des Moines

Simply print the form below, fill it out and mail it with your check (made payable to Iowa CCI) to:

Iowa Citizens for Community Improvement
2001 Forest Avenue
Des Moines, IA 50311

Your Information:

Name(s) of people attending:

_______________________________________________________

Address: ________________________________________________

Town/State/Zip: __________________________________________

Phone: _________________________________________________

Email: __________________________________________________

I heard about CCI's convention from: _________________________

Registration:
Select one registration option below

                                                                  By 7/3       After 7/3

Family at hotel                                           __$100          __$120

Individual at hotel                                     __$80           __$100

Family not staying at hotel                        __$45          __$65

Individual not staying at hotel                   __$35          __$55

Family 1 day only, not at hotel                   __$30           __$50

Individual 1 day only, not at hotel             __$25           __$45

       If one day only, which day:                 __Friday     __Saturday

Friday's John Nichols' Keynote Only         __$15 in advance

I would also like to donate $_____ to help offset convention costs.

Please apply my CCI Get It Done Club discount of ____%.

Total # of people attending: ________________

Total amount enclosed: $___________________

__Check   or    __Credit card

Mastercard__    Visa__

Discover__    American Express__

Card Number: __________________

CVV2 code (3 digit # on back of card): ____

Expiration Date: __Month  __Year

Signature: _____________________