Conference Registration

First Name

Last Name

Badge Name

Title

Company/Association

Industry

JT&S

G&T

Dist&Oper

Address

City

State

Zip Code

Spouse/Guest Name

Office Phone

Cell Phone

Email

Emergency Contact Name & Number

Please Let Us Know If You Will Be Attending The Following Activities

Activities

Welcome Reception (Sunday Evening)

Sponsor Reception (Tuesday Evening)

Number Attending Welcome Reception

Number Attending Sponsor Reception

Please Indicate What You Will Attend

Breakfast (choose one):

Quad State Breakfast

SAIA Breakfast

Member Breakfast

Lunch (choose one):

New Member Luncheon

Past Chair Luncheon

Member Luncheon

New members are strongly encouraged to attend the New Member's Luncheon.

Registration Cost

Member Conference Registration

Number Attending

$750 per person.

Member Conference Total

Non-Member Conference Registration

Number Attending

$900 per person.

Non-Member Conference Total

Spouse/Guest Registration

Number Attending

$100 per person. Not attending the conference. Includes 3 breakfasts, 2 lunches, and both receptions.

Spouse/Guest Total

When attending events, members and guests must wear name badges.

Sunday Outings

Golf Outing

Number Attending

$85 per person.

Golf Total

NASCAR Hall of Fame

Number Attending

$35 per person.

NASCAR Hall of Fame Total

Golf Club Rental

I will need to rent golf clubs $35

Golf clubs are on a first come first served basis.

Clubs Right vs Left

Right Handed

Left Handed

Total

$

I would like to pay by

Mail

Credit Card

Card Number

Expiration Month

Expiration

CVC

Billing Address

Address 1

Address 2

City

State/Province

Zip/Postal