****USE THIS FORM ONLY IF USING A DIFFERENT CREDIT CARD
FROM REGISTRATION FORM****
Health Physics Society’s 60th Annual Meeting
12-16 July 2015 - Indianapolis, Indiana
Name for badge: (First)_______________________________ (Last)________________________________________________
Address:_______________________________________________________________________________________________
City:____________________________________ State:_______________ Zip/Postal Code:______________________________
Phone:_______________________________________ Fax:______________________________________________________
Email (for confirmation):________________________________ If Registering-Companion Name:_______________________
LOWER FEE DEADLINE 9 JUNE 2015
REGISTRATION: (Mark Appropriate Box) Preregistration Fees On-Site Fees
q Companion (Receptions, Breakfast, Mon. Lunch) $110.00 $110.00
q Emeritus Companion (Receptions, Breakfast) $ 55.00 $ 55.00
EXTRA TICKETS: (Mark Appropriate Box) Preregistration Fees On-Site Fees
q Additional Tues. Awards Dinner Ticket(s) # of Tickets ______________ $ 67.00 $ 67.00
q AAHP Awards Lunch Ticket(s) (Tues.) Guest $ 15.00
$ 15.00
One ticket comes with meeting registration
SOCIAL PROGRAM Preregistration Fees On-Site Fees Total $
q Cultural Trail Bike Tours (Sat 7/11, 5:30pm) Prereg Only, Must have bike
# of Tickets____No Fee $________
q Downtown Orientation Tour (Sun 7/12, 2:00-3:30pm) Prereg Only
# of Tickets____No Fee $________
q Active Indy Walking Tour, Monuments (Mon 7/13, 9:30-11:30am)
# of Tickets____X $15
# of Tickets____X $20 $________
q Annual HPS 5K RUN/WALK (Tues 7/14, 6:30-8:30am) # of Tickets____X $25
# of Tickets____X $30 $________
Run/Walk - Shirt Size: Sq Mq Lq XLq XXLq (XXL is available with Preregistration Only)
q 60th Anniv Dallara Indycar Factory, Motor Speedway (Tues 7/14, 8:45am-3:15pm) # of Tickets____X $75adult # of Tickets____X $80adult $________
# of Tickets____X $60kids # of Tickets____X $65kids $________
q Eiteljorg Museum of American Indians & Western Art (Wed 7/15, 10am-5pm) # of Tickets____X $10adult # of Tickets____X $15adult $________
# of Tickets____X $5 kids # of Tickets____X $10kids $________
q Pub Crawl (Wed, 7/15, 6:00pm) # of Tickets____X $20
# of Tickets____X $25 $________
Pub Crawl - Shirt Size: Sq Mq Lq XLq XXLq XXXLq (XXL and XXXL are available with Preregistration Only)
q Night Out “Animals and all that Jazz” (Thurs 7/16, 5:00-9:00pm) # of Tickets____X $40adult # of Tickets____X $45adult $________
# of Tickets____X $30kids # of Tickets____X $35kids $________
PAYMENT INFORMATION - HPS TAX ID # 04-6050367
Check Payment: Health Physics Society, 1313 Dolley Madison Blvd., Suite 402, McLean, VA 22101 CHECK #_____________
Cardholder’s Information
qVISA q MasterCard q American Express q Discover
Card Number __________________________________________________Exp. Date_________________ CV2___________________
Credit Card Billing Address: ______________________________________________________________________________________
Cardholder Name:__________________________________________Phone Number________________________________________
Signature: ________________________________________ Email Address for receipt________________________________________
PAYMENT MUST ACCOMPANY THIS FORM
Registration Total Extra Tickets Total
Social Program Total
TOTAL FEES ENCLOSED $___ ________
$___________
$___________
$___________
q Please check the box to confirm you have read and understand the Cancellation/Substitution Policies
Cancellation/Substitution Policy: Substitutions of meeting participants may be made at any time without penalty. All conference and tour cancellations must be in writing and must reach the HPS Office by 9 June to receive a refund. All refunds will be
issued after the meeting minus a 20% processing fee. Refunds will not be issued to no-shows.