2023 PARTICIPANT REGISTRATION Annual SCJMHS Conference 41st Annual South Central Joint Mine Health & Safety ConferenceApril 3-5, 2023 ~CHOCTAW CASINO RESORT~ Durant, OK Company Name:* Company Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Person completing this form:* First Last Email* Phone*Please select one of the following groups* Alumina Coal SS&G (Crushed Stone, Sand and Gravel) Dimensional Stone Cement Clay UG M/NM (Underground Metal/Nonmetal) Other M/NM Salt Participants AttendingIF 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?*1 Participant Attending2 Participants Attending3 Participants Attending4 Participants Attending5 Participants Attending6 Participants Attending7 Participants Attending8 Participants AttendingParticipant #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 InformationName First Last Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 CardCard 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. EmailThis field is for validation purposes and should be left unchanged. Have questions? Contact Us