2023 PARTICIPANT REGISTRATION

Annual SCJMHS Conference

41st Annual South Central Joint Mine Health & Safety Conference

April 3-5, 2023 ~CHOCTAW CASINO RESORT~ Durant, OK

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 8 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
Participant #7
First Last
Job Title - Participant #7
MSHA ID NUMBER per Location - Participant #7
Participant #8
First Last
Job Title - Participant #8
MSHA ID NUMBER per Location - Participant #8
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:
We will print the name badges from the Names and Job Titles entered above. The Discussion Group refers to the meetings / workshops being held during the Conference (this will enable us to allocate appropriate space for each group).
Total Due
$0.00
Credit Card
Card Details
Cardholder Name
Cancellation / Refund Policy:
-50% refund for cancellations before March 1, 2023
--NO registration refunds for NO SHOWS or cancellations after March 25, 2023
-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.
Phone
This field is for validation purposes and should be left unchanged.

2023 PARTICIPANT REGISTRATION

Annual SCJMHS Conference

Participants Attending

Card Billing Information

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