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23rd ANNUAL SYMPOSIUM ON ALCOHOL
         BEVERAGE LAW & REGULATION REGISTRATION FORM

REGISTRANT NAME

BADGE NAME (if different from registrant name)

ORGANIZATION								                                                             TITLE (required)

ADDRESS

CITY, STATE & ZIP

TELEPHONE								FAX

E-MAIL

ITINERARY (This information is crucial for food function guarantees. Thank you for your cooperation.)

ARRIVAL 3/____ /16 ____ AM / PM	 	 DEPARTURE 3/____ /16 ____ AM / PM

_____ Lodging at Westin Alexandria		            _____ Lodging at other hotel or local resident

Other Requests (including diet restrictions & allergies): ______________________________________________________
CLE credit requests (Please list the states of request along with Bar number.)

State:	 __________	 __________	  __________	    __________
				                             __________	    __________
Bar #:	 __________	 __________	

REGISTRATION FEES (The registration fee includes attendance at the symposium, all meal functions and program materials.)

                                                                                                                             AFTER FEBRUARY 19TH

Appointed Control State Representative                                                             Waived  Waived
Member and Non-Member: State and Governmental Agencies                                              $295    $345
Member: Industry/Trade Association (Supplier, Broker, Association, Allied)                          $595    $645
Non-Member: Industry/ Trade Association (Supplier, Broker, Association, Allied)                     $895    $945

PAYMENT METHOD (this portion of the form will be shredded immediately after processing)

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, February 19, 2016. Note: Due to new Payment Card Industry
(PCI) compliance guidelines all registrations with credit card information must be submitted via secure fax to (703) 824-3377, mail or online. NABCA can
no longer accept emailed registrations that include credit card information.

ED CHECK ENCLOSED (payable to NABCA)	 OR	 		 		 
AIVCREDIT CARD NUMBER					
FEE WPRINT CARDHOLDER’S NAME				                EXPIRATION DATE	                 	  	                         $
                                                                                                           AMOUNT

                                                        AUTHORIZED SIGNATURE			                            DATE

                                                Submit This Form To:

         NABCA Meetings Department • 4401 Ford Avenue, Suite 700 • Alexandria, Virginia 22302

                   Tel: (703) 578-4200 • Secure Fax: (703) 824-3377 • Online: www.nabca.org
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