Check one:
Registration
Complimentary Registration
Contact Information (person to contact if questions on registration:
City:
Company Name:
Contact Name:
State:
Zip:
Contact email:
Enter Name(s) of Person(s) registering.  
1.
Check here if first time attendee
Name
Title:
email:
Phone:
2.
Check here if first time attendee
Name:
Title:
email:
Phone:
3.
Check here if first time attendee
Name:
Title:
email:
Phone:
4.
Check here if first time attendee
Name:
Title:
email:
Phone:
If new attendee, provide name of person who referred you to our conference
Check here if you need EFT information
Check here if you will be mailing a check
Mail
U.S. funds check  issued to Utility Payment Conference to address listed on left
Check here if you are paying with your American Express , Discover, MasterCard or Visa card
Check here if you need a receipt
Check here if you need an invoice.
Total Amount Due:
Add $25 to total if paying with a debit/credit card.
Code of Conduct, Cancellation and Change Policy
Prior to submitting your registration form, read the Code of Conduct,  Change and Cancellation and Waiver Information.  Your
submitted Registration Form indicates you have read, understand and accept all terms and conditions sited within the
Conference Waiver Information.  
Photo Release
I/We hereby give the Utility Payment Conference and its delegated representatives the permission to photograph me alone
and/or with other attendees in conjunction with and for the conference.  I/We understand the pictures may be used for the
promotion of the conference.  Publications of photographs shall include, but is not limited to, the conference website, future
conferences, promotional brochures and flyers and other forms of media.
Liability Release Waiver Information
My/Our registration indicates I/We agree to release the Utility Payment Conference and hotel, and each of their respective
officers, directors, agents, representatives, and employees (referred to collectively as "Releasees") from any and all claims,
actions, damages and liabilities, injury or loss that in any way are caused by, arise out of or result from my participation in the
Utility Payment Conference.
Hotel Reservation Release
I/We hereby give the Utility Payment Conference and its delegated representatives permission to inquire of the hotel information
regarding my booked reservation.  In addition, the conference hotel(s) has my/our permission to disclose my/our reservation
information to the conference's delegated representation.
www.paymentconference.com
Fill out this form ONLY if you are a Communication, Cooperative, Municipality or Utility representative

Enter each persons contact information.  Cost is per person for company employee only.          
              
Registration Cost Per Person: Add $25 (per person) if paying with a debit or credit card.

$650 - May 1 - August 31
$750 - September 1 - October
Utility Payment Conference