2008 Georgia Highway Safety Conference--Registration

2008 GEORGIA HIGHWAY SAFETY CONFERENCE ONLINE REGISTRATION FORM

PLEASE FILL IN THE REQUESTED INFORMATION.

REGISTRATION FEES INCLUDE WELCOME RECEPTION, 2 LUNCHES, 2 CONTINENTAL BREAKFASTS, REFRESHMENT BREAKS, EXHIBITS, WORKSHOPS, AND PROGRAM MATERIALS. AFTER FILLING OUT THIS FORM, YOU WILL BE REQUIRED EITHER TO PAY VIA CREDIT CARD ONLINE OR SEND A CHECK OR PURCHASE ORDER DIRECTLY TO GOHS.

First Name:

Last Name:

Preferred first name on badge:

Organization:

Address:

City:

State:

Zip:

Telephone:

Fax:

Email Address:

Additional Email Address:

Additional Email Address:

Please list any special requirements that you may have for this conference:

May we print your information in our conference materials? Yes
No

What field do you work in? Automotive Industry
Judge/Prosecutor
State or Federal Government
Advocacy/Consumer Group
Child Passenger Safety
Public Safety
Community Programs
Law Enforcement
EMS/Medical
Insurance Industry
Other

If other, what field do you work in?

Registration Fees: (Check One) Late/On-Site Registration After June 30, 2008--$225
Presenter/Speaker--No Charge
Presenter/Speaker-One day, Day of attending presentation only--No Charge
Exhibitor--No Charge

Is your company exhibiting at this year's conference? Yes
No

If so, what is the name of your company?

If exhibiting, how many people from your company will be present? (Guestimates are o.k.)

If you are a One Day Presenter/Speaker, please indicate the day here:

Check here if you want to sign up for the MADD Georgia Golf Tournament (separate fees. see conference website for more information)

Payment Method: Visa
Master Card
Check
Purchase Order

PLEASE NOTE THAT GOHS IS USING PAYPAL FOR CREDIT CARD REGISTRATION. IF THE CARD YOU USE IS ASSIGNED TO A PAYPAL ACCOUNT ALREADY, YOU WILL HAVE TO PAY MANUALLY FOR REGISTRATION AFTER FILLING OUT THIS FORM OR YOU WILL BE CONTACTED BY A REPRESENTATIVE FROM GOHS TO FINISH YOUR REGISTRATION.

Card Number:

Expiration Date:

CW2 Code (3 digit code on back of the card):

Telephone Number Assigned to Credit Card Billing Address:

Email Address Assigned to Credit Card (if any):

If PO, please enter billing address: Check if same as above

Attention:

Organization:

Address:

City:

State:

Zip:

Initial here to accept the Terms of Registration listed below

By initialing here, I authorize Georgia Governor's Office of Highway Safety to charge the selected registration fees to the card number supplied according to the card issuer agreement or to invoice the supplied purchase order. Confirmation of your registration will be sent to you via email. I acknowledge that cancellations must be submitted in writing prior to July 10, 2008 to receive a refund minus the $25.00 processing fee. No shows will not receive a refund. Registration packets may be picked up on-site at the Westin Savannah Harbor Golf and Spa Resort and will not be mailed. Registrations received without payments or Purchase Order number will NOT be processed. If you have questions regarding your registration, please contact Helen Bagley at 404-656-6996 or via email at hbagley@gohs.ga.gov. Please remember that you will be required to make your own room reservation to the Westin Savannah Harbor Golf and Spa Resort and can do so at the Travel/Hotel section of the Conference website. PLEASE ALSO REMEMBER THAT GOHS IS USING PAYPAL AND IF THE CREDIT CARD USED IN YOUR REGISTRATION IS ASSIGNED TO A PREEXISTING PAYPAL ACCOUNT, YOU WILL HAVE TO MANUALLY REGISTER FOR THE CONFERENCE USING THIS LINK.

First Name:
Last Name:
Preferred first name on badge:
Organization:
Address:
City:
State:
Zip:
Telephone:
Fax:
Email Address:
Additional Email Address:
Additional Email Address:
Please list any special requirements that you may have for this conference:
May we print your information in our conference materials?	Yes No
What field do you work in?	Automotive Industry Judge/Prosecutor State or Federal Government Advocacy/Consumer Group Child Passenger Safety Public Safety Community Programs Law Enforcement EMS/Medical Insurance Industry Other
If other, what field do you work in?
Registration Fees: (Check One)	Late/On-Site Registration After June 30, 2008--$225 Presenter/Speaker--No Charge Presenter/Speaker-One day, Day of attending presentation only--No Charge Exhibitor--No Charge
Is your company exhibiting at this year's conference?	Yes No
If so, what is the name of your company?
If exhibiting, how many people from your company will be present? (Guestimates are o.k.)
If you are a One Day Presenter/Speaker, please indicate the day here:
Check here if you want to sign up for the MADD Georgia Golf Tournament (separate fees. see conference website for more information)
Payment Method:	Visa Master Card Check Purchase Order
PLEASE NOTE THAT GOHS IS USING PAYPAL FOR CREDIT CARD REGISTRATION. IF THE CARD YOU USE IS ASSIGNED TO A PAYPAL ACCOUNT ALREADY, YOU WILL HAVE TO PAY MANUALLY FOR REGISTRATION AFTER FILLING OUT THIS FORM OR YOU WILL BE CONTACTED BY A REPRESENTATIVE FROM GOHS TO FINISH YOUR REGISTRATION.
Card Number:
Expiration Date:
CW2 Code (3 digit code on back of the card):
Telephone Number Assigned to Credit Card Billing Address:
Email Address Assigned to Credit Card (if any):
If PO, please enter billing address:	Check if same as above
Attention:
Organization:
Address:
City:
State:
Zip:
Initial here to accept the Terms of Registration listed below
By initialing here, I authorize Georgia Governor's Office of Highway Safety to charge the selected registration fees to the card number supplied according to the card issuer agreement or to invoice the supplied purchase order. Confirmation of your registration will be sent to you via email. I acknowledge that cancellations must be submitted in writing prior to July 10, 2008 to receive a refund minus the $25.00 processing fee. No shows will not receive a refund. Registration packets may be picked up on-site at the Westin Savannah Harbor Golf and Spa Resort and will not be mailed. Registrations received without payments or Purchase Order number will NOT be processed. If you have questions regarding your registration, please contact Helen Bagley at 404-656-6996 or via email at hbagley@gohs.ga.gov. Please remember that you will be required to make your own room reservation to the Westin Savannah Harbor Golf and Spa Resort and can do so at the Travel/Hotel section of the Conference website. PLEASE ALSO REMEMBER THAT GOHS IS USING PAYPAL AND IF THE CREDIT CARD USED IN YOUR REGISTRATION IS ASSIGNED TO A PREEXISTING PAYPAL ACCOUNT, YOU WILL HAVE TO MANUALLY REGISTER FOR THE CONFERENCE USING THIS LINK.