2024 PARTICIPANT REGISTRATION

Annual SCJMHS Conference

42nd Annual South Central Joint Mine Health & Safety Conference

March 25-27, 2024

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 Quantity
$375.00 per registrant includes all meals & refreshments served by the Conference, including attending the and any sessions or workshops. DISCLAIMER: By Registering for the conference, you understand photographs will be taken and used on our website. All Company and personal information will be protection. WE DO NOT SHARE ANY LIST OF PARTICIPANTS. Thank you for your support!!
Price:
We will print the name badges from the Names and Job Titles entered above.
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.
Email
This field is for validation purposes and should be left unchanged.

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2024 PARTICIPANT REGISTRATION

Annual SCJMHS Conference

Participants Attending

Card Billing Information

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