EXPO - GEAPS

GEAPS EXCHANGE 2011 REGISTRATION FORMType or print all information; photocopy this form as needed for additional registrants. Fax or mail completed form (with payment)to GEAPS: Fax (00-1) 952-929-1318; Mail 4248 Park Glen Rd, Minneapolis MN 55416 USA, or register online at www.geaps.com.PLEASE PRINT CLEARLY1. Are you a GEAPS member?circleYesone Regular Associate Affiliate StudentChapterNo Check this box to become a new GEAPS member.Include $265 (annual member dues) in your registration paymentto become a GEAPS member through June 2012.2. DelegateFIRSTNICKNAME (IF DIFFERENT)Is your company exhibiting? No YesEXHIBITOR REGISTRATION OPTIONSExhibiting companies receive two complimentary Exhibitor Registrations per10’x10’ booth. These include all expo hours and educational sessions fromSunday to Tuesday. Additonal Exhibitor Registrations can be purchased at aspecial rate. Guests, optional and à la carte events can be added below.6. Exhibitor RegistrationComplimentaryAdditionalPRE-REGISTRATION RATESBefore Jan. 27 After Jan. 27n/cn/c$285 $330LASTDELEGATE REGISTRATION OPTIONSJOB TITLECOMPANY7. Delegate Full RegistrationIncludes all education and expo events andall of the à la carte events belowMemberNon-MemberPRE-REGISTRATION RATESBefore Jan. 27$710$975After Jan. 27$820$1,085MAILING ADDRESSCITYZIP/PCCOUNTRYSTATE/PROV8. One Day Registration (Please specify which day)Includes education and expo for one day onlySunday Monday TuesdayMemberNon-Member$260$390$300$450PHONEE-MAILFAX9. GuestsFull RegistrationIncludes all of the à la carte events belowBase Registration$410$100$470$1153. Guest (Guests are non-industry individuals—spouses or significantothers—who will accompany the delegate above.)FIRSTNICKNAME (IF DIFFERENT)10. à la carte EventsGet-Acquainted Party (Sat.)President’s Reception & Banquet (Tues.)Guests only: “Beautiful Portland Tour” (Sun.)Guests only: “Oregon Vineyard Tour” (Mon.)$100$90$65$105xx$110$105$75$120xxLASTHOME MAILING ADDRESSCITY STATE/PROV ZIP/PC11. Optional Activities (not included in “Full Registrations”)Fun Run (Sun.)Seashore Tour (Wed.)Columbia Gorge Tour (Wed.)Kalama Facility Tour (Wed.)Guests only: “Portland Underground” (Tue.)Guests only: “Chocolate Decadence” (Tue.)n/c$135$110$35$30$75xxxxn/c$150$125$40$35$85xxxxHOME PHONEE-MAILWill you or your guest need any special accommodations due to a disability ordietary needs? Check here to be contacted by a member of the GEAPS staff.4. Is this your first time attending a GEAPS Exchange?Yes No5. Check this box if you do not want to receivepre-/post-conference information from Exchange Expoexhibitors about their products and services.DO NOTWRITE HERE12. Payment Enclosed — US funds onlyIndicate total payment and circle one; must be received with registration.Total Payment: $Check or Master/Visa/AmExAccount NumberExpiration Date / Print NameSignatureDate Amt Check RegDO NOTWRITE HERE19