PARTICIPANT REGISTRATION

Company Name:*
Company Address*
Street Address Address Line 2 City State ZIP Code
Person completing this form:*
First Last
Email*
Phone*
Participants Attending
IF REGISTERING MORE THAN 6 PERSONS, please fill out additional form. NOTE: We will print the name badges from the Names and Job Titles entered below.
How many Participants Attending?*
Participant #1
First Last
Job Title - Participant #1
MSHA ID NUMBER per Location - Participant #1
Participant #2
First Last
Job Title - Participant #2
MSHA ID NUMBER per Location - Participant #2
Participant #3
First Last
Job Title - Participant #3
MSHA ID NUMBER per Location - Participant #3
Participant #4
First Last
Job Title - Participant #4
MSHA ID NUMBER per Location - Participant #4
Participant #5
First Last
Job Title - Participant #5
MSHA ID NUMBER per Location - Participant #5
Participant #6
First Last
Job Title - Participant #6
MSHA ID NUMBER per Location - Participant #6
Discussion Group
Discussion Group Selection*
The Discussion Group refers to the meetings on Wednesday morning of the Conference (this will enable us to allocate appropriate space for each group).
NIOSH Interventions Pre-Conferance
The NIOSH Mining Program presents: An Overview of NIOSH Interventions and Technologies to Identify, Manage, and Reduce Risks. A pre-conference seminar of the South Central Mine Health & Safety Conference. Monday April 15, 2019 | 8:00am - 3:30pm | The Holton Anatole, Dallas, Tx (LIMITED Seating registrations must be in by April 1, 2019.) Pre-conference seminars are offered as optional activities for conference attendees. Seminar registration is separate from the regular conference fee, and covers the venue, materials.
Pre-Conferance Attendees*
How many attendees will be coming to the pre-conferance that will NOT attending the full conference. $75 each
Attendee #1
First Last
Email for Attendee #1
Attendee #2
First Last
Email for Attendee #2
Attendee #3
First Last
Email for Attendee #3
Attendee #4
First Last
Email for Attendee #4
Attendee #5
First Last
Email for Attendee #5
Awards Lunch Participant Only
If you have participants that will be attending only the Awards Lunch please select them here.
Awards Lunch Onlys Attending*
Each Attending at a cost of $50 each
Awards Attendee #1
First Last
Email for Awards Attendee #1
Awards Attendee #2
First Last
Email for Awards Attendee #2
Awards Attendee #3
First Last
Email for Awards Attendee #3
Awards Attendee #4
First Last
Email for Awards Attendee #4
Card Billing Information
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Participants Attending
$375.00 per registrant (includes all meals & refreshments served by the Conference, including attending the Awards Luncheon and any sessions or workshops)
Price: $375.00
Total Due
$0.00
Cancelation / Refund Policy:
-50% refund for cancelations before March 15, 2019
--NO registration refunds for NO SHOWS or cancelations after April 1, 2019
-There is no additional fee charged for changing names (swapping attendees) on registrations PROVIDING notice is prior to conference start date, after that a $25 processing fee be charged.

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PARTICIPANT REGISTRATION

Participants Attending

Discussion Group

NIOSH Interventions Pre-Conferance

Awards Lunch Participant Only

Card Billing Information

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