Attendee Registration Form

Document Sample
Attendee Registration Form Powered By Docstoc
					                                                                Please submit one registration form per attendee. Complete all sections of
                                                                the registration form and return with payment to E-Scrap Conference, PO Box
                                                                42270, Portland, Oregon 97242-0270 or fax to 503.233.1356. Duplicate this
                                                                form when registering more than one person from an organization. If pay-
                                                                ment is made for multiple attendees attach all individual registration forms to

Attendee Registration Form                                      the check. For registration questions, contact Jef Drawbaugh at 503.233.1305
                                                                or jef@resource-recycling.com.
September 23-24 2009 Orlando, Florida

Name (as you would like it to appear on name tag)                                            Title


Company Name


Address


City / State / Zip                                                                           Country


Phone / Fax


Email

   Check here if you require assistance, or special accommodations    E-Scrap 2009 Registration Fee
   because of a disability, to make this program accessible to you.   Registration includes two continental breakfasts, two lunches,
   Someone from the conference office will contact you. Special       refreshment breaks, conference packet and admission to all
   request must be given to the conference office at least 10         E-Scrap 2009 sessions, tradeshow, and evening reception.
   working days prior to the conference.                              Conference registration does not include lodging. All E-Scrap
   Check here if you would like a vegetarian meal for the             Conference sessions will be held at the Hilton Orlando. Onsite
   luncheons.                                                         registration is subject to a $100 processing fee in addition to the
   Check here if you would like a kosher meal for luncheons.          late registration fee of $440. Registration fee is per person.
   Check here if you are a BrokerBin.com member and you’ll
   receive $35 off the registration fee.                              Received by September 1st
   Check here if you are an ISRI member.                                $415 - One from your organization
                                                                        $400 each - Two or more from your organization

Payment              Total Due$                                       Received after September 1st
Full payment must accompany this registration application. Your         $440 - One from your organization
confirmation and receipt will be emailed to the email address           $425 each - Two or more from your organization
provided above. If you do not receive an email within 48 hours,
please resubmit your registration form.                               Additional Educational Opportunities
                                                                      The following workshops will be held on September 22nd
   Check (payable to Resource Recycling)                              in conjunction with the E-Scrap Conference. For additional
   Credit Card (check one):    Visa      MC       AMX                 information, visit www.e-scrapconference.com.

                                                                                                     Received by          Received after
                                                                                                     September 1st        September 1st
Card Number                                 Exp Date
                                                                      Certification in electronics Recycling - R2/RIOS
Billing Address                                                         8:00 am - 12:00 pm          $95 ISRI member/   $125 ISRI member/
                                                                                                     $125 non-member      $150 non-member
                                                                         1:00 pm - 5:00 pm           $95 ISRI member/     $125 ISRI member/
City / State / Zip                          Country                                                  $125 non-member      $150 non-member
                                                                      Optimizing Profits in Electronics Recycling - R2/RIOS
                                                                        8:00 am - 12:00 pm         $95 ISRI member/     $125 ISRI member/
Name on Card                                                                                         $125 non-member      $150 non-member
                                                                         1:00 pm - 5:00 pm           $95 ISRI member/     $125 ISRI member/
Signature                                                                                            $125 non-member      $150 non-member
                                                                      Performance Measures for Electronics Recycling Programs:
Office Use Only:                                                      How Can we Measure Effectiveness?
JDDB                 CBDB         Payment             Badge              1:00 pm - 4:00 pm       $100                $125

Additional Activities:                                                e-Stewards Certification
                                                                         2:00 pm - 5:00 pm           Free                 Free