Conference Registration

*Name

*Position

*Company

*Address

*City

*State/Province AB AK AL AR AZ BC CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MB MD ME MI MN MO MS MT NB NC ND NE NH NJ NL NM NS NT NU NV NY OH OK ON OR PA PE QC RI SC SD SK TN TX UT VA VT WA WI WV WY YT Other *Zip Code

*Country

*Phone

Fax

*Email Address *

*First Name for Badge

*Registration confirmation will be sent to this address only.

This is my first DiRōNA conference

I am a new DiRōNA member this year

The conference registration fee includes the cost for attendance at all general sessions, workshops, social functions and planned meals.

Total Registration Fees: $0

The following events are included in the full registration fee. As an accommodation for spouses and guests accompanying fully registered conference participants, tickets are available for individual meal and social functions. Reservations for these events must be made in advance and the total charges included in your remittance. If a guest wishes to attend the general sessions, they must purchase a full conference registration or day pass.

Name of Guest

Total Guest Fees: $0

Name

Day Phone

Night Phone

Please check here if you require special accommodations or dietary needs to fully participate.

Needs are:

Sorry, DiRōNA cannot bill you. All fees must be pre-paid and must accompany the registration form. All registrations must be received no later than October 21, 2011. After this date, you must register onsite. A confirmation will be emailed to you once your payment has been processed.

If you wish to pay by check, please complete a printed copy of the registration form and submit it by mail with your payment.

Conference Registration Fee: $0
Guest Fee: $0
Total Guest Fees: $0

*Card Type American Express Discover MasterCard Visa

*Name On Card

*Card Number

*Expiration Date January February March April May June July August September October November December 2011 2012 2013 2014 2015 2016 2017

*CVV Code

Written notice of cancellation must be received at DiRōNA Headquarters no later than Friday, October 21, 2011 in order to receive a refund, less a $75 processing fee. There will be no refunds for cancellations received after this date. "No Shows" will be charged at the full conference rate. All refunds will be processed after the conference.

By clicking this button, you agree to pay the registration fee noted as the "Total" above using the credit card infomration provided.