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2014 FGFOA Annual Conference Registration Form <br /> Online registration also is available at www.fgfoa.org. Please do not send in this form if you are registering online. Return <br /> completed form with registration fees to:FGFOA Annual Conference, P.O. Box 1757,Tallahassee, FL 32302. Make checks payable <br /> to FGFOA Annual Conference. Please type or print information requested.Complete a separate form for each registrant.Advance <br /> registration will not be processed without payment. MasterCard and Visa credit cards are accepted and can be faxed to(850) 222- <br /> 3806.This form is for conference registration only and not for hotel reservations. <br /> Please type or print clearly. <br /> Full Name: First Name or Nickname: <br /> (As you wish it to appear on your badge) <br /> Title: Affiliation: <br /> (City, County or Company,etc.) <br /> Mailing Address: <br /> City: State: Zip: <br /> Work Phone: <br /> Email Address: <br /> First-Time Attendee?: ❑ Yes ❑ No <br /> Office Contact Person: Phone: <br /> Method of Payment: ❑ Check(payable to FGFOA) ❑ Visa ❑ MasterCard <br /> Credit Card Number: Expiration Date: <br /> Card Holder's Name: Card Holder's Signature: <br /> Billing Address for Credit Card(if different from above): <br /> City: State: Zip: <br /> PAYMENT AND CLASS ROSTER (FOLLOWING PAGE) MUST ACCOMPANY EACH REGISTRATION <br /> Early Fee Late Fee Fee Paid <br /> By 05/7/2014 After 05/7/2014 Special Needs: If you are <br /> Registration Type(Please check only one) physically challenged and <br /> require special services,or <br /> FGFOA Active Member $ 225.00 $ 265.00 <br /> if you have special dietary <br /> FGFOA Associate Member $ 285.00 $ 325.00 needs,please attach a <br /> FGFOA Non-Member $ 345.00 $ 385.00 written description to your <br /> Ethics Seminar $ 65.00 $ 75.00 advance registration form. <br /> Pre-Conference Seminar Cancellations:Must be <br /> FGFOA Active Member $ 90.00 $ 130.00 received and confirmed <br /> FGFOA Associate Member $ 130.00 $ 170.00 in writing by 5:00 p.m., <br /> FGFOA Non-Member $ 165.00 $ 205.00 Friday,May 16,2014, <br /> to entitle registrant to <br /> Other Fees and Guest Tickets a refund of registration <br /> Guest Association Night Tickets $ 30.00 $ 40.00 fees,less a$40.00 <br /> Guest Tuesday Night Event Ticket $ 50.00 $ 60.00 administrative fee. <br /> Teen Tuesday Night Event Ticket(13-18) $ 25.00 $ 35.00 <br /> Child Tuesday Night Event Ticket(3-12) $ 25.00 $ 35.00 Office Use Only <br /> Golf Tournament* $ 90.00 $ 90.00 Payment Received <br /> ('}bu must be pre-registered in order to play in the GofTournament) Check# <br /> Pairing Preference: Date Received <br /> Total Amount Due: Amount <br /> .r. <br /> 19 <br /> 12 <br />