Northern Illinois Roundtable - Meeting Registration

Please use the form below to register your meeting attendance. If more than one person from your company is attending please register each person separately.
 

First Name:
Last Name:
Company:
Address:
City, State Zipcode:
Phone number with area code:
Fax number with area code: 
Email:

Fees:
Cost per company is $400 per year. If you are unsure if your company has already made payment choose "Please Invoice Me" option and we will verify if payment has been made prior to invoicing.

If you chose "Credit Card" follow the instructions below before clicking the submit button.

NOTE FOR CREDIT CARD PAYMENTS ONLY:

If you are making payment by credit card:

  1. Print a copy of this form now - before clicking the submit button

  2. Write in the following information

  3. Fax to: 1-928-213-9763

Credit card number: __________________________________________________

Expiration Date: ____ Month   ____ Year

Name on card: ______________________________________________________

Total amount to be charged: $__________ (US)

Email address for receipt (if different than the above registration email address):

__________________________________________________________________ 

 

 

Facility Issues ©  2010

Voice: (928) 213-9767
Fax: (928) 213-9763

Mailing Address: PO Box 1447, Flagstaff, AZ 86002 --1447 USA