2012 Fall Technical Seminar & Expo October 10 – 13, 2012 ... - IKECA

Three Easy Ways to Register:On-line at www.ikeca.org, Mail or FaxCONTACT INFORMATIONPlease print your name and company exactly how you would like it published.Registration Form2012 IKECA Technical SeminarOctober 10 – 13, 2012 | Indianapolis, INCrowne Plaza at Historic Union StationName (Attendee 1):Nickname (for Badge):Company Name:Companion Name:AddressCity: State/Province: Zip:Telephone:Email (REQUIRED):Special Needs/Dietary Requirements:Emergency Contact (Name/Phone):q Check here if this is your organization’s first IKECA Fall Technical SeminarADDITIONAL ATTENDEES (Add additional attendees and reception/spouse/companions on the following page):Name (Attendee 4):Nickname (for Badge):Attendee Email:Name (Attendee 5):Attendee Email:Emergency (Name/Phone):Nickname (for Badge):Emergency (Name/Phone):q Check here if you would like to register for an exam and download the exam application here.Early Bird Rates (Available Until September 17, 2012) Regular Rates (After September 17, 2012)Quantity Attendee Type Fee Total Quantity Attendee Type Fee TotalFirst Attendee $490 First Attendee $565Additional Attendee $340 Additional Attendee $415First AttendeeNon-Member$650PAYMENT INFORMATION - All registrations must be prepaid. Please make checks payable to IKECA in US DollarsTotal Registration Amount: $:_____________________AttendeeNon-MemberOSHA $215 OSHA $215OSHANon-MemberSpouse/companion(full access)$315$340Reception Only $50Dine Around Dinner(10/10)Individual PayOSHANon-MemberSpouse/companion(full access)Reception Only$50Dine Around Dinner(10/10)Payment Type q Check Enclosed made payable to IKECA q Visa q American Express q MasterCardCard Number: Exp. Date CVV#Name of Card HolderSignature$730$315$340Individual Pay