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GOVERNOR'S <br />HURRICANE CONFERENCE <br />Office Use: <br />2019 Governor's Hurricane Conference° Registration Form <br />NAME Badge Name <br />AGENCY <br />ADDRESS <br />STATE ZIP <br />PHONE( ) <br />UNTY <br />CITY <br />EMAIL <br />check here if you do not want your email address released <br />❑ Training only (May 12 - 15) $135 if postmarked by March 8 $155 if postmarked after March 8 <br />❑ Conference only (May 15 - 17) $260 if postmarked by March 8 $280 if postmarked after March 8 <br />❑ Training & Conference (May 12 - 17) $285 if postmarked by March 8 $305 if postmarked after March 8 <br />t1f_registering for Training,_please complete the Training Session Se[ ection_Form.posted in march) -on -our website_ under_ the Program/Registration Tabes <br />Email Form to: ghcrene(a)verizon.net; or <br />Fax Form to: (727) 944-2687; or <br />Mail to: PO Box 279, Tarpon Springs, FL 34688-0279 (Do not mail checks after April 19th <br />Checks payable to: Governor's Hurricane Conference, Inc. <br />CREDIT CARD REGISTRATION: ❑American Express ❑MasterCard []Visa ❑Discover <br />Account Number Exp. Date (Re uired <br />Required: Security Code <br />Complete billing address if different than above <br />Print name as it appears on card <br />Signature Required: <br />(We cannot process your registration without a signature and an amount authorized.) <br />$ total authorized for this registration <br />Refund requests must be received in writing no later than March 29, 2019. A $50 per registration processing fee will be applied to all refunds. Requests after March <br />29th will be considered for approval after the conference in June. <br />Office use only: 43 <br />