2012 Convention Registration Form

REGISTRATION FEE (Includes two lunches, reception, and dinner function and registration materials for ONE PERSON) $300.00

Note: Registration forms SUBMITTED TOGETHER from the same state board or school will qualify for a discount. Please contact The Conference office for more information.

Name:

Organization and Title:

Address:

City:

State/Province:

Zip:

Phone:

E-mail Address:

Guest's Name:

*The above contact information will be shared with other attendees. NOTE: If you do NOT want your contact info shared, please contact The Conference staff. If you would like to receive text alterts pertaining to the annual meeting, please email your cell phone number to admin@theconferenceonline.org

I WILL BE ATTENDING (Please check which functions you plan to attend.)

Please check ONE of the following meetings that you will attend on Wednesday, February 29:

Association of Executive of Funeral Service Boards Meeting
8:00 a.m. - 12:15 p.m. (Executive Level Regulatory Staff)
          Or
Funeral Service Education Forum
11:00 a.m. - 12:15 p.m. (Mortuary Science Educators)
          Or
Presentation for Jurisdiction Board Members
11:00 a.m. - 12:15 p.m. (State & Provincial Board Members)
          Or
None

If your guest(s) will be attending any of the following functions with you, please indicate the number of extra tickets you need, total the ticket amount to the left.

Opening Session and Luncheon (Wednesday, February 29)

Extra Tickets for guests @ $30.00 each

Guest Name(s):

The Welcome Reception (Wednesday, February 29)

Extra Tickets for guests @ $20.00 each

Guest Name(s):

Awards Luncheon (Thursday, March 1)

Extra Tickets for guests @ $30.00 each

Guest Name(s):

Dinner Function (Thursday, March 1)

Extra Tickets for guests @ $40.00 each

Guest Name(s):

Total Amount Due: $300

PLEASE NOTE: All registrations received after JANUARY 25, 2012 (including on-site) will be charged the on-site fee of $300.00 per individual.

All tickets (if required) will be in your registration packet, which you will pick up at the Convention Registration Desk at the hotel.

You are responsible for making your own hotel reservations! Contact the Peabody Little Rock, no later than February 13, 2012, at 1-501-906-4000.

Please mention that you are with ICFSEB to ensure the room rate.

Hotel Negotiated Room Rate is $129 per night, plus tax.

Are you a licensed Funeral Service Practitioner subject to Continuing Education Requirements?

Yes No

Please list state you are licensed in:

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