UI Interstate Benefit Conference

Please fill in the form to register for the 2009 Unemployment Insurance Interstate Benefits and Federal Programs Training Conference.

All fields with an "*" beside them are required. If you have any questions, please contact Doris Bruce at 850.921.3848 or email at Doris.Bruce@awi.state.fl.us.

Contact Information First Name: *
Last Name: *
Title: *
Agency/Company Name: *
Address: *
Address 2:
City: *
State: *
Zip: *
Phone: *
Email Address: *
Confirm Email Address: *
Special Accomodations Needed:
Emergency Contact Name:
Emergency Contact Phone:

Enter number of guests attending, if any, and guest names. Guest Fees will be collected at the door.

Number of Guests attending (Wednesday evening event only): ($50 each, collected by check at the door)
Guest Names (separated by commas):

Payment Information Amount: $300.00
Payment Type: Credit Card Mailed Check

PO Number On-site*

No credit cards are accepted on-site.

If paying by check, please mail them to:
Ingrid Evans/NASWA
2009 UI IB Federal Training Conference Registration
National Association of State Workforce Agencies
444 North Capitol Street, N.W.
Suite 142
Washington, D.C. 20001

Enter PO Number, if applicable:

Enter credit card information if using a credit card. Please make sure that the address is the billing address.

Credit type: Visa MasterCard

American Express Discover*

Credit Card Number: *No hyphens or spaces
Expiration Month: *
Expiration Year: *

Credit Card Billing Address

Fill in the following information if using a credit card ONLY. Please verify the billing address and phone number.

Click box to use contact info above:

First Name:

Last Name:

Address:

City:

State:

Zip:

Phone: (xxx)xxx-xxxx

* Denotes required field

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