Name:
Title:
Organization:
Street Address:
2nd Street Address:
City:
State/Province:
Zip/Postal Code:
Country:
Phone:
FAX:
E-mail:
URL:
	Type of Business or Profession.
	Please Describe your business.
	What is your Tribal Affiliation (of individual)?
	Is your company certified as MWBE?: yes no
	Please list all agencies with whom you are certified.
	What AICCT Banquet Sponsorship would you like? Turtle Island .... $5,000.00 Golden Eagle .... $2,500.00 White Buffalo .... $1,500.00 Red Hawk .... $700.00 Black Wolf .... $300.00 Member before 10/27/2008 .... $40.00 Member after 10/27/2008 .... $50.00 Nonmember before 10/27/2008 .... $50.00 Nonmember after 10/27/2008 .... $65.00

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