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2013 FGFOA Annual Conference Registration Form <br /> Return completed form with registration fees to: FGFOA Annual Conference, P.O. Box 1757,Tallahassee, FL 32302.Make checks <br /> .)ayable to FGFOA Ann za1 Confer ice. Please type or print information requested. Complete a separate form for each registrant. <br /> Advance registration will not be processed without payment. MasterCard and Visa credit cards are accepted and can be faxed to(850) <br /> 222-3806.This form is for conference registration only and not for hotel reservations. Online registration also is available at www. <br /> fgfoa.org..Pka3e d,D nci send in t1115 form if you are reJisx rir_g orlinL, <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 /> E-mail 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(fdiferentfrom above): <br /> City: State: Zip: <br /> PAYMENT AND CLASS ROSTER (REVERSE SIDE) MUST ACCOMPANY EACH REGISTRATION <br /> Early Fee Late Fee Fee Paid <br /> By 05/23/2013 After 05/23/2013 Special Needs:If you are <br /> Registration Type (Please check only one) physically challenged and <br /> FGFOA Active Member $ 225.00 $ 265.00 require special services, or <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 $ 55.00 $ 65.00 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 <br /> Friday,May 31,2013, <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 /> (*You must be pre-registered in order to play in the Golf Tournament.) Check# <br /> Pairing Preference: Date Received <br /> Total Amount Due: Amount <br /> 21 <br /> 32 <br />