JSUCC Conference Registration
 

Please provide the following registration information:

First Name
Last Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
FAX
E-mail

Registration fee includes:  Conference Sessions 9/18 & 9/19 with Continental Breakfast,  one Luncheon and Dinner Banquet for one.  

Please provide the following ordering information:

DESCRIPTION	PRICE	QTY	TOTAL
Conference Registration	$ 150.00
Guest Keynote Speaker Luncheon 9/18	$   26.00
Guest Dinner Banquet 9/18	$   30.00
Golf Tournament 9/17	$   56.00
TOTAL

Choose one of the following State Meetings you will attend:

Alaska
Idaho
Montana
Oregon
Washington

	BILLING
Credit Card	VISA MasterCard American Express Diner's Club Discover
Cardholder Name
Card Number
Expiration Date

	BILLING
Purchase Order #
Account Name

Comments:  (note names of attendees here if different than above)