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ADMINISTRATORS CONFERENCE REGISTRATION FORM 2016
REGISTRANT NAME BADGE NAME
ORGANIZATION TITLE (required)
ADDRESS
CITY, STATE & ZIP
TELEPHONE E-MAIL
SPOUSE/GUEST NAME BADGE NAME
TELEPHONE SPOUSE E-MAIL
ITINERARY (This information is crucial for food function guarantees. Thank you for your cooperation.)
REGISTRANT ARRIVAL 10 /____ / 16 ____AM / PM DEPARTURE 10 /____ / 16 ____AM / PM
SPOUSE/GUEST ARRIVAL 10 /____ / 16 ____AM / PM DEPARTURE 10 /____ / 16 ____AM / PM
OTHER REQUESTS (Including dietary restrictions and food allergies): ____________________________________
REGISTRATION FEES This conference is INVITATION ONLY. AFTER SEPTEMBER 23RD
WAIVED
ADVISORY COMMITTEE MEMBER (CONTROL STATE) WAIVED $345
$745
NON-COMMITTEE MEMBER STATE REPRESENTATIVE $295 $245
INDUSTRY ADVISORY COMMITTEE/TRADE ASSOCIATION $695
SPOUSE/GUEST (FEE COVERS MEAL FUNCTIONS ONLY.) $195
PAYMENT INFORMATION
No registration will be processed without an accompanying check made payable to NABCA or authorization
to bill your VISA, MasterCard or American Express. DO NOT SEND REGISTRATION FORM WITHOUT
PAYMENT. Early registration ends on Friday, September 23, 2016. NOTE: Due to Payment Card Industry
RE(PCI) compliance guidelines all payments with credit card information MUST BE SUBMITTED VIA SECURE FAX
GIto (703) 824-3377 or mail. NABCA can no longer accept emails that include credit card information.
STI hereby authorize the National Alcohol Beverage Control Association to charge my credit card for the amount below. In the case of any issues or disputes concerning
RAthis transaction I will notify NABCA promptly to rectify the situation prior to notifying my credit card company.
FEE W TIONPRINT CARDHOLDER'S NAME
AIVEDInternal Use ONLY Auth#______________ CC#____________________ Initial_________________ Date_________________
AUTHORIZED SIGNATURE DATE
This portion of the form will be shredded immediately after processing.
CHECK ENCLOSED (payable to NABCA) —OR—
CREDIT CARD NUMBER $
EXPIRATION DATE AMOUNT
SEND THIS FORM TO Mail: NABCA 4401 Ford Avenue, Suite 700 Alexandria, Virginia 22302
Secure Fax: (703) 824-3377 • Online: www.nabca.org
