CONGRESSIONAL STAFF REGISTRATION
Attendee Information
First Name
*
:
Last Name
*
:
Title:
Organization
*
:
Street Address
*
:
Street Address 2:
City
*
:
State
*
:
Choose One
Does Not Apply
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Country:
ZIP
*
:
Phone
*
:
Cell Phone:
Your Twitter Handle:
Fax:
E-Mail
*
:
Please make sure that this is a valid email account.
Your receipt for payment and/or the hotel acknowledgement will be sent there.
If you would like a second copy of your confirmation sent,
please enter the e-mail address here:
Preferred Name on Badge (FIRST NAME ONLY)
*
:
Attendee(s) has special needs
*
:
Yes
No
If Yes, Please Specify:
Name of Accompanying Spouse/Partner:
No registration fee for spouse/partner.
First and Last Name of Spouse/Partner:
Spouse/Partner Gender:
Male
Female
Registration Payment Information
Registration Fees
:
Late/On-Site Registration Fee
(After May 4, 2018 and On-Site):
$1,050
Refunds will be made for cancellations received in writing by May 4, 2018 (less a $200.00 service fee). NO REFUNDS will be made for cancellations received after May 4, 2018.
Will you be requesting a hotel room?
*
Choose One
-----
Yes
No
NOTE: If you select "No" a link will be included in your confirmation email that will allow you to request a room at a later time.
Please return to online registration center.