Sample Conference Registration

COMPLETE THIS FORM AND (Invoice will be created after submission) 1. Mail payment or purchase order with Invoice to: Your Address Here Your Address Here Your Address Here 2. Fax with credit card information or purchase order to: (505) 555.5555 3. Questions?: Call (505) 555.5555 or (505) 555.5555 or email: Conference Email All Fields Marked with * Are Required Registrant Information Billing Information First Name* Last Name* Middle Name Job Title* Service Affiliation Home Address* City* State* Warning: include(C:\Sambar\docs\salter\sample_conference_include\state.inc) [function.include]: failed to open stream: No such file or directory in C:\Apache2\htdocs\salter\conference\sample\index.php on line 76 Warning: include() [function.include]: Failed opening 'C:\Sambar\docs\salter\sample_conference_include\state.inc' for inclusion (include_path='.;C:\php5\pear') in C:\Apache2\htdocs\salter\conference\sample\index.php on line 76 Zip* Home Phone* Work Phone Fax # Email* Billing Information Pick a payment Method* Warning: include(C:\Sambar\docs\salter\sample_conference_include\payamethod.inc) [function.include]: failed to open stream: No such file or directory in C:\Apache2\htdocs\salter\conference\sample\index.php on line 108 Warning: include() [function.include]: Failed opening 'C:\Sambar\docs\salter\sample_conference_include\payamethod.inc' for inclusion (include_path='.;C:\php5\pear') in C:\Apache2\htdocs\salter\conference\sample\index.php on line 108 Check Number Paying Agency P.O. # Contact Person Billing Address Billing City Billing State Warning: include(C:\Sambar\docs\salter\sample_conference_include\state.inc) [function.include]: failed to open stream: No such file or directory in C:\Apache2\htdocs\salter\conference\sample\index.php on line 137 Warning: include() [function.include]: Failed opening 'C:\Sambar\docs\salter\sample_conference_include\state.inc' for inclusion (include_path='.;C:\php5\pear') in C:\Apache2\htdocs\salter\conference\sample\index.php on line 137 Billing Zip Code Billing Daytime Phone Squad Name (If you are part of a squad please choose a squad name and enter it into box below)

Pre-Conference Workshops (Monday, July 23 – Wednesday, July 25)

Warning: include(C:\Sambar\docs\salter\sample_conference_include\connect.inc) [function.include]: failed to open stream: No such file or directory in C:\Apache2\htdocs\salter\conference\sample\index.php on line 162

Warning: include() [function.include]: Failed opening 'C:\Sambar\docs\salter\sample_conference_include\connect.inc' for inclusion (include_path='.;C:\php5\pear') in C:\Apache2\htdocs\salter\conference\sample\index.php on line 162

Warning: mysql_select_db() [function.mysql-select-db]: Access denied for user 'ODBC'@'localhost' (using password: NO) in C:\Apache2\htdocs\salter\conference\sample\index.php on line 163

Warning: mysql_select_db() [function.mysql-select-db]: A link to the server could not be established in C:\Apache2\htdocs\salter\conference\sample\index.php on line 163
Could not select database: Access denied for user 'ODBC'@'localhost' (using password: NO)

Pre-Conference Workshops (Monday, July 23 – Wednesday, July 25) Info on All Pre-Conference Sessions	Cost	Check To Register