Page 4 - 2017 January Board Meeting - IAC

NABCA JANUARY BOARD OF DIRECTORS MEETING 2017

REGISTRATION FORM

REGISTRANT NAME BADGE NAME

ORGANIZATION

ADDRESS

CITY, STATE, ZIP E-MAIL

TELEPHONE CELL PHONE

ASSISTANT NAME ASSISTANT E-MAIL ASSISTANT TELEPHONE

SPOUSE NAME BADGE NAME

TELEPHONE SPOUSE E-MAIL
ITINERARY

(This information is crucial for food functions & rooming guarantees. Thank you for your cooperation.)
Registrant Arrival 01/_______ /17 _______ AM/PM Departure 01/_______ /17 _______ AM/PM
Spouse Arrival 01/_______ /17 _______ AM/PM Departure 01/_______ /17 _______ AM/PM
Yes, I will attend the dinner on 1/8. Yes, I will attend the dinner on 1/9.

LODGING INFORMATION

NABCA has secured a room rate of $300.00 for single/double occupancy plus 13% taxes. The room rate includes the resort fee,
complimentary high-speed internet in guest rooms, resort fitness center, and beach shuttle transportation.
Room Type: ____King ____Queen/Queen Other Requests:_______________________________________
(including dietary restrictions or food allergies)
PAYMENT INFORMATION

I 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 this
transaction I will notify NABCA promptly to rectify the situation prior to notifying my credit card company.

PRINT CARDHOLDER’S NAME AUTHORIZED SIGNATURE DATE
Internal Use ONLY Auth#__________________ CC#______________________ Initial___________________ Date___________________
NOTE: Due to new Payment Card Industry (PCI) compliance guidelines all payments with credit card information MUST BE
SUBMITTED VIA SECURE FAX to (703) 824-3377 or mail. NABCA can no longer accept emails that include credit card information.

This portion of the form will be shredded immediately after processing.

REGISTRATION FEE: $995.00 CHECK ENCLOSED (payable to NABCA) -or-

/ $
CREDIT CARD NUMBER EXPIRATION DATE AMOUNT
CONFIRMATION CANCELLATION INFORMATION

Please note: You will receive a reservation confirmation email All rooms are guaranteed for late arrival by NABCA. In order to
directly from the hotel. NABCA will send a second confirmation avoid penalties, please notify NABCA 48 hours prior to arrival of
email with further important details 1-2 weeks prior to the meeting. any cancellations or changes in stay.

RETURN BOTH THE REGISTRATION FORM AND THE ACTIVITY FORM
NO LATER THAN MONDAY, DECEMBER 12, 2016!

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