Registration Form 2015 NACD Washington Fly-In April 28-April 29 Full Name: ____________________________________________ Nickname for Badge: __________________________________ Title: ______________________________________________________________________________________________________ Company Name: _____________________________________________________________________________________________ Company Address: ___________________________________________________________________________________________ City: ___________________________ State: ______________ Zip +4 (REQUIRED w/ plus 4): ___________________________ Phone: Fax: E-mail: __________________________________________ Cell Phone Number: ___________________________________Twitter@:___________________First-Time Attendee? YES/NO Spouse/Companion Name: ____________________________________ Nickname for Badge: ______________________________ Home Address: (Needed for Congressional appointments)____________________________________________________________ City: ___________________________ State: ______________ Zip+4 (REQUIRED w/ plus 4): ____________________________ Please list any other Senators/Representatives**, in whose district(s) your company has additional facilities, with whom you would like to meet:__________________________________________________________________________________________________ Please list any members of Congress, or staff, with whom you have a pre-existing relationship: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Please list any Fly-In attendee(s) you would like to have attend the same meetings (If possible, such as spouse, child, employees, etc.): ____________________________________________________________________________________________________________ **Please note that Congressional offices determine meeting availability. NACD cannot guarantee meetings. ************************************************************************************************************ REGISTRATION FORMS DUE APRIL 17, 2015 Late registrations are accepted, but make scheduling Hill meetings very difficult. As such, it is advisable to register early. _____________________________________________________________________________________________________________________________ 2015 NACD Washington Fly-In, April 28 - April 29, 2015 Includes: Briefing Materials, Congress “101” Orientation, Congressional Reception, Wednesday Breakfast, Hospitality Room, Lunch Member Rate: $395 x____ = $______ Emerging Leader Rate: $199 x_____= $_____ Please list any dietary restrictions: __________________________________ Please check this box if you would like to participate in meetings with key Regulatory Officials, instead of returning to the Hill on the morning of April 29. _____________________________________________________________________________________________________ � American Express � Master Card TOTAL: � Visa � Check/Money Order payable to NACD enclosed $______ Credit Card # ________________________________________ Sec. Code: ___________Expiration Date: _______________ Card Member’s Name (Print): ________________________________Signature:______________________________________ Fax form to (703) 527-7747 or send with payment to: NACD, 1560 Wilson Blvd., Ste. 1100, Arlington, VA 22209. Fly-In cancellations must be submitted in writing to NACD. Any cancellations received 15 business days prior to first day of event will be refunded minus an administrative charge of 25% of the gross registration and activities fees. Any cancellations after this date will not be eligible for refunds. Substitutions can be made at any time. No refund for no-shows. Hotel Accommodations with group rate of $269 S/D: The Ritz-Carlton Pentagon City in Arlington, VA, 1-800-241-3333 under NACD Washington Fly-In Room Block. Group code CADCADA. Hotel deadline is April 6, 2015. Contact Doug Leigh at [email protected] or 571-482-3069 for questions about the Fly-In.
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