Please print or type all information. One individual per form please. This form may be photocopied for additional registrants.
Registrant’s Full Name and Degree (if applicable)_____________________________________________________________________________________________
Job Title ______________________________________________________________________________________________________________________________
Organization Name _____________________________________________________________________________________________________________________
Mailing Address_________________________________________________________ City ________________________ State __________ZIP ______________
Telephone____________________________________________________ Email ___________________________________________________________________
Assistant’s Name & Email ________________________________________________________________________________________________________________
First Name/Nickname (to appear on badge)_________________________________________________________________________________________________
Emergency Contact Name and Telephone __________________________________________________________________________________________________
National Provider Identifier (NPI) Number (if applicable) _______________________________________________________________________________________
IQL Annual Conference (September 27–28, 2019) By August 9 August 10–September 6 After September 6
Includes IQL General Sessions, Peer-to-Peer Breakouts,
and meal functions with exhibitors.
AMGA Member or Corporate Partner o 850 o 950 o 1,050
AMGA Non-Member o 1,700 o 1,900 o 2,100
Leadership Councils (September 26, 2019)
Participation in the AMGA Leadership Councils is
limited to the members of the Councils only. If you are unsure
of your status, please contact Joe DeLisle at email@example.com
or 703.838.0033 ext. 355.
Leadership Council Meeting o 275 o 275 o 275
Please select which council you are attending:
o CAO/COO o CEO/President/Chair o CFO o CMO/Medical Directors o CNO o Quality
Spouse/Guest of IQL
This fee covers the Welcome Reception on Thursday, September 26, as well as breakfasts,
lunches, and receptions on September 27 and 28. Spouse/Guest Fee o 175
Spouse/Guest of Leadership Council Reception
This fee covers the Council welcome event on Wednesday, September 25. Spouse/Guest Fee o 75
Name of Spouse/Guest ____________________________________________________________________
Spouse’s/Guest’s First Name/Nickname (to appear on badge) ____________________________________
Cancellations must be submitted in writing by Friday, August 16 in order to receive a
refund, less a $100 cancellation fee. After this date, cancellations will receive a Letter of
Credit for the amount paid, less a $100 cancellation fee.
o Check, in the amount of _____________, is enclosed.
o Please charge _____________ to my o Visa o MasterCard o American Express
Card number Expiration date Security Code
Cardholder’s Name (please print) Signature
Questions? Contact Bruce Hadloc at firstname.lastname@example.org or 703.838.0033, ext. 366.
For more information, visit amga.org/IQL19
Registration Form AMGA’s 2019 Institute for Quality Leadership September 26–28, 2019 • Delano Las Vegas • Las Vegas, Nevada
Total Amount Due:
Three Ways to Register
Online, by visiting amga.org/IQL19
Fax form with credit card payment to 703.548.1890
Mail registration form and check (payable to AMGA)
or credit card payment to:
AMGA, One Prince Street
Alexandria, VA 22314-3318