2016 NCPO Registration Information

2016 NCPO Registrant Information

Please complete the following information for member and guest NCPO attendees by Friday, October 30, 2015.

*Note that information submitted on this form will be used on the 2016 NCPO website.

Due to the date for food and beverage guarentees, and overall costs to participants based upon the number of RSVPs received, cancellations will be assessed a fee of $500 per cancellation after Tuesday, December 1, 2015. This fee will be assessed for any reason associated with cancellation and will apply to all registrants. This cancellation fee was approved by NCPO Chief Executives in 2011.

NCPO Member Registrant Information

First Name *This question is required.

Last Name *This question is required.

Nickname (for badge)

Designation *This question is required.

NCPO Organization *This question is required.

Street Address *This question is required.

Address Line 2

City *This question is required.

State / Province / Region *This question is required.

Postal / Zip Code *This question is required.

Country *This question is required.

Email Address *This question is required.

Work Phone *This question is required.

Cell Phone (onsite)

Dietary Restrictions

Special Needs

Mission Statement

Attendee Profile

1. Attendee Photo

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2. Organizational Logo

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Will you be attending the Thursday evening Welcome Reception and Dinner? *This question is required.

Will a guest/spouse be attending the Thursday evening Welcome Reception and Dinner? *This question is required.

Will you be attending the Friday Dinner? *This question is required.

Will a guest/spouse be attending the Friday Dinner? *This question is required.

Emergency Contact Information

First Name

Last Name

Phone

Email This question requires a valid email address.

Administrative Assistant Information

First Name *This question is required.

Last Name *This question is required.

Phone *This question is required.

Email *This question is required. This question requires a valid email address.

Guest / Spouse Registrant Information

First Name

Last Name

Nickname (for badge)

Dietary Restrictions

Special Needs

Additional Family Members / Children Information (1)

First Name

Last Name

Nickname (for badge)

Dietary Restrictions

Special Needs

Additional Family Members / Children Information (2)

First Name

Last Name

Nickname (for badge)

Dietary Restrictions

Special Needs

Questions?

Please contact Patrick Dougherty, Senior Director, Meetings & Conventions at NCPA, at 800-544-7447 x2693 (toll free) or patrick.dougherty@ncpanet.org.