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

Note: Registration cancellations incur an administrative fee.         
October - December 31 - $475 - Early Bird Registration
January 1 - April - $575 - Early Registration
May 1st - August 31 - $675
September 1 - Septemeber 15 - $775
Utility Payment Conference
Registration Information