2018 Diversity Conference Registration FormDate *Need ADA Accommodation? *YesNoFull-Time Student? *YesNoPart of 5-Member Team? *YesNoMeal Preference? *ChickenFishSaladPrefix: *NoneDr.MissHon.Rev.Mr.Mrs.Ms.Select the prefix that you prefer.Name #1 *FirstLastPhoneEmailSection DividerName #2FirstLastPhoneEmailSection DividerName #3FirstLastPhoneEmailSection DividerName #4FirstLastPhoneEmailSection DividerName #5FirstLastPhoneEmailSection DividerDivision/Discipline/Department Name *Classification *AdministratorFacultyStaffStudentPhoneEmail *Company/Organization Name *Company/Organization Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeConference Registration FeesLate (After March 31) **Full-Time Student: $195.00Regular Registrant: $525.00Student Group Discounted Fee - 4 Students: $702.00Student Group Discounted Fee - 5 Students: $877.50Student Group Discounted Fee - 10 Students: $1,755.00Test $0.00*Full-Time Student Registration Fee Discount PolicyTotal$ 0.00Please enter the credit card information requested below. *Card NumberSecurity CodeName on CardExpirationMM123456789101112/YY1920212223242526272829NameSubmit