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Company Name:
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Company Contact Name:
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Company Contact email:
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Company Address:
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State:
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Zip:
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City:
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Complimentary Registration
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Check One:
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Registration
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Name
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Phone:
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1.
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email:
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Title:
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Check here if first-time attendee. Provide name of person who referred you to our conference
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2.
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Phone:
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Name:
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email:
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Title:
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Check here if first-time attendee. Provide name of person who referred you to our conference
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Phone:
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3.
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Name:
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Title:
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email:
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Check here if first-time attendee. Provide name of person who referred you to our conference
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Phone:
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4.
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Name:
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email:
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Title:
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Check here if first-time attendee. Provide name of person who referred you to our conference
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Check here if you will be mailing a check for payment. Address is on left
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Check here if you need EFT information to make a payment.
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Check here if making credit card payment. Add $10 per person for a credit card administrative fee.
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Check here if you need an invoice
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Check here if you need a receipt
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Total # registering:
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Total Amount Due:
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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.
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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.
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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.
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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.
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