2019 Annual Conference Registration Form

2019 LASIE ANNUAL CONFERENCE REGISTRATION

November 20-22, 2019
"WORKERS' COMPENSATION NO CALL: TIME TO CHANGE THE RULES"
Full Name *

First Name Last Name
Name for Badge *

First Name Last Name
Company *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *

Area Code Phone Number
E-mail *

Registration Type *

	LASIE Member Rates	Non-Member Rates
FULL REGISTRATION (10/1/19- 11/15/19) Members $455 Non-Members $555
FULL REGISTRATION FOR ADDITIONAL COMPANY REGISTRANTS (10/1/19- 11/15/19) Members $420 Non-Members $545
WEDNESDAY SINGLE DAY REGISTRATION Member $235 Non-Member $285
THURSDAY SINGLE DAY REGISTRATION Member $320 Non-Member $375
FRIDAY SINGLE DAY REGISTRATION Member $50 Non-Member $60
FULL REGISTRATION FOR ADDITIONAL SPONSOR REPS Member / Non-Member $350
FULL REGISTRATION FOR NON-INDUSTRY RELATED SPOUSE OR COMPANION Member/ Non-Member $150 *PUT NAME FOR BADGE BELOW**

Non-Industry Spouse/ Companion

First Name Last Name
If you are filling out the form for someone else and would like the invoice sent to you instead, please fill out the following infromation.
Recipient Name

First Name Last Name
Recipient Email
example@example.com
PAYMENT REQUEST

Please note that all credit card payments include a transaction fee. Once your registration form has been received by our staff an invoice will be sent.

Payment Method *

	Yes
Credit Card Payment - CONVENIENCE FEE APPLIES
Check (Bill my Company)

Should be Empty: