Registrant Information
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Affiliation:
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Facility Name or Group Practice
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Post-Title:
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For "Other" post-title, please note in Remarks section below. |
Badge Name:
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Enter nickname or leave blank if same as above
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Specialty:
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Transportation
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Arrival Information:
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Offered on June 11 ONLY from Kona Airport
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Hotel Reservation
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Check-In Date:
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Use format MM/DD/YYYY; date you will arrive
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Check-Out Date:
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Use format MM/DD/YYYY; date you will depart
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Room Type:
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Transportation
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Departure Information:
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Offered on June 15 ONLY to Kona Airport
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Full Guest Names In This Room
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Guest 1 or Self:
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Guest 1 Age:
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Enter age if under 18
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Guest 2:
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Guest 2 Age:
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Enter age if under 18
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Guest 3:
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Guest 3 Age:
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Enter age if under 18
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IMPORTANT:The payment options below are with regard to the Conference Package Price ONLY (See Hotel Room Type category above). We will invoice you SEPARATELY for all guests. Balance for all guests will also be due by April 1, 2006. |
Hotel Package Payment Options
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Payment Plan*:
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I will pay the full package balance now
I will pay $500 deposit now and remit balance on or before April 1, 2006
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If paying $500 Deposit, choose one:
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Card Type:
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MC, Visa, AmEx, Discover
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Card Number:
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Enter your credit card number
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Expiration Date:
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Enter the expiration date of your credit card
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Authorized Signature:
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Sign here to authorize payment
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Billing Address:
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City:
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Postal Code:
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State or Country:
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E-mail Address:
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Please enter your e-mail address so that we may send you a confirmation.
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Other Contact Information:
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Enter in a mailing address if different from above, plus any telephone and/or fax numbers where we can reach you.
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