Conference Registration 2017 AL/MS APA Annual Conference Registration Form Date: October 4-6, 2017 Location: Birmingham, Alabama: DoubleTree by Hilton For general conference information, contact Mac Martin, AICP. For issues with online registration, please contact our webmaster. Step 1 of 3 33% Name* First Last Check the box below if you prefer that a nickname or other name be used for your conference ID. I would like to input an alternate name. Name First Last Organization / Company*Job Title*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Work Phone*Work Phone ExtensionFaxCell PhoneEmail* Enter Email Confirm Email APA Membership NumberEmergency Contact Name First Last Emergency Contact PhoneAre you completing this form on behalf of another person?*YesNoYour Name* First Last Your Phone*Your Email* Are you registering multiple people?*YesNoEnter additional names here.First NameLast NameAICP? Are you AICP-certified?*YesNo Registration Type (check all that apply)* General - $250 Speaker Registration - $150 Retired Planner - $125 Student - $50 (must be currently enrolled) Awards Luncheon Guest - $50 Conference Transportation Fee - $30 Chapter Sponsor - $0 Conference Transportation Fee*YesNoIf you participate in a mobile workshop and/or need transportation to a chapter social? There is a one-time $30 fee that must be checked above.Please ensure that you select a registration quantity that matches the number of individuals you have registered.General Registration* Price: $250.00 Quantity: Speaker Registration* Price: $150.00 Quantity: Retired Planner Registration* Price: $125.00 Quantity: Student Registration* Price: $50.00 Quantity: Awards Luncheon Guest Registration* Price: $50.00 Quantity: Chapter Transportation Fee* Price: $30.00 Quantity: Number of Chapter Sponsorship Registrations*12Total $0.00 Total $0.00 Payment Method*Credit Card (via PayPal)Credit Card (on-site at check-in)Check / Purchase OrderSponsorship RegistrationYou will be taken to the PayPal page to complete your purchase upon clicking the Submit button below.Payment will be due upon check-in at the conference. Registration and other fees will not be refunded after September 29th. We will be able to accept Visa, MasterCard, Discover, and American Express for those who wish to pay via credit card at check-in.Payment will be due no later than check-in at the conference. Registration and other fees will not be refunded after September 29th. If you are paying by check or purchase order, please make your check payable to Alabama Chapter - APA. Mail your payment to: Greg Clark, ALAPA Treasurer 150 Violet Place Eufaula, AL 36027 For questions regarding payment via check or purchase order, contact Greg Clark at: Phone: 334.262.4300 Email: email@example.comPurchase Order NumberIf one or more registrations are included with your sponsorship, please indicate the sponsoring organization's name below.Sponsoring Organization*EmailThis field is for validation purposes and should be left unchanged.