Independent Insurance Agents of Indiana, Inc.

Prefix
* First Name
* Name on badge
* Last Name
* Agency or Business Name
* Email
* Daytime Phone
* Address Line 1
* City
* State
* Zip
EXHIBITORS - Booth location preference #1
EXHIBITORS - Booth location preference #2
EXHIBITORS - Employee Working Tradeshow
EXHIBITORS - Tradeshow Employee's Email
License #
License Expiration Date (mm/dd/yyyy)
What is your role in your organization:

Input fields with an asterisk (*) are required.

I agree that by registering for this Event, I will allow the information that I have provided in this registration form (excluding financial and disability information) as well as my image or likeness to be reproduced by IIABA or the sponsoring state association ("Sponsor") in any media, including, for example, electronic or print form, for use on web sites, or in any other publications, promotions, or presentations created by the Sponsor, in the Sponsor's sole discretion.

This item is no longer available for purchase.

2018 Indiana Big "I" Annual Convention