ATTENDEE REGISTRATION

ATTENDEE

REGISTRATION

ATTENDEE INFORMATION

Attendee First and Last Name*

Preferred Name

If different from above. (This will appear on your name tag.)

Attendee Company Name*

Street Address*

City*

State*

Zip Code*

Attendee Phone Number*

Phone

Attendee Email Address*

Registration Option (select one)*

Includes meals listed below, based on conference date(s) selected.

Registration for FULL conference - $450

Registration for Tuesday, October 28 ONLY - $350 (includes keynote presentation)

Registration for Wednesday, October 29 ONLY - $200

Meal Attendance (select all that apply)*

Based on the conference registration option you selected above, please let us know which meals/events you plan to attend during your conference stay.

Tue, October 28, Breakfast

Tue, October 28, Lunch

Tue, October 28, Reception

Wed, October 29, Breakfast

Wed, October 29, Lunch

Wed, October 29, Reception

Wed, October 29, Social Event

Thur, October 30, Breakfast

Please Note Any Dietary Needs Here

BILLING INFORMATION

Please complete the section below if the attendee information you entered above is different from your company's billing information.

Please include your company's accounts payable contact information, if applicable.

Is the Attendee Information Entered Above to be Used for Billing?*

An invoice will be emailed to you (or the accounts payable contact listed below, if included) within 3 business days of submitting this registration. Please follow the instructions in that email to complete your payment.

Please submit your payment promptly as registrations are not considered complete until payment has been received.

If you need assistance please reach out to hminnix@va811.com.

Select

Company Name

Company Mailing Address

Company Phone Number

Phone

Company Accounts Payable Contact

Company Accounts Payable Phone Number

Phone

Company Accounts Payable Email Address

You Are Responsible For Making Your Hotel Reservations.

Once you select the submit button below a new page will open that contains booking links to hotels in the conference room block.

Is Your Company Interested in Being a Conference Sponsor?

If so, please contact Frank Giannini, Virginia 811's Manager of Public Awareness

(fgiannini@va811.com or 540-240-1234) for more information.

Send me a copy of my responses

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