Print Form ASAP Records Management Training Registration Course No. 1102 February 26, 2015 – National Archives and Records Administration – Washington, D.C. American Society of Access Professionals, Inc. 1444 I Street, NW, Suite 700, Washington, D.C. 20005-6542 E-Fax: 202-216-9646 Analog Fax: 202-216-0246 E-Mail: [email protected] Please register by completing the form below and submit to ASAP with your payment information. Telephone registrations or incomplete registrations ARE NOT accepted. SAVE $$$$$ - register on-line! (Dues must be current to receive member pricing.) 1) Registrant Name and Address Information: Please print/type clearly and avoid using abbreviations for agency names/components. Registration lists, name badges, certificates, etc. are based on this information. Last Name: ___________________________________________ First Name: ____________________________________________ Nick (Badge) Name: ___________________________________________ Title: _______________________________________________________________________________________________________ Agency/Org/.: ________________________________________________________________________________________________ Component/Office: ___________________________________________________________________________________________ Mail Address: ________________________________________________________________________________________________ _______________________________________________________________________________________________ City, State, Zip: ______________________________________________________________________________________________ Registrant's Email (Required): _________________________________________________________________________________ Tele: _______________________________________________________________________________________________________ 2) Please list any special needs. ASAP, in compliance with the ADA, is happy to assist. ________________ ________________________________________________________________________________________ YES NO ASAP is a nonprofit, professional member society. 3) ASAP Member? Federal, state or local government employment does not automatically give one ASAP membership or member discounted program fees. YES NO Publish my name/organization/telephone/E-mail in the Networking List (for registrations received by Feb. 23) Payment: Registration MUST be accompanied by a credit card and authorized signature or completed training authorization form (SF182) including signature AND billing instructions. ASAP requires three business days for registration processing of paper registrations. Submitting registration without payment authorization does not hold seat nor fee structure. PLEASE REFER TO THE POSTED POLICIES AT WWW.ACCESSPRO.ORG, INCLUDING THE CANCELLATION POLICY 4) Attendance and Tuition/Fees: Please check the correct attendance and the fee structure (in US dollars). Tuition is a PER PERSON cost, regardless of attendance in person or by live streaming. NOTE FOR LIVE STREAMING: A Certificate of Attendance will be issued only to the paid registrant after the program and submission of program evaluation form. ASAP relies on the integrity of the individual and/or agency or company to honor the pricing structure. By selecting this option it is understood that the policy will be honored. In Person Attendance LIVE STREAM Per Person Per Person 1st Early Bird Member (Until Jan. 23) ______ 375 ______ 450 2nd Early Bird Member (Until Feb. 6) ______ 425 ______ 500 Member (After Feb. 6) ______ 475 ______ 550 1st Early Bird Nonmember (Until Jan. 23) 2nd Early Bird Nonmember (Until Feb. 6) Nonmember (After Feb. 6) ______ 515 ______ 565 ______ 615 ______ 465 ______ 515 ______ 565 5) Payment: Please complete appropriate payment information below. Check/ Money Order Enclosed: Check # ___________________ Amount: $________________ Signed Training Authorization Attached (SF-182) Credit Card (VISA, MasterCard, American Express, IMPAC. Cards are processed within three days or sooner of submission. The system automatically emails receipts to the cardholder when the transaction is processed. Cardholders MUST provide a valid email address. CARD HOLDER INFORMATION - ALL FIELDS ARE REQUIRED. Receipts are automatically emailed to cardholders with successful transactions. LAST FOUR DIGITS of Card : ____ ____ ____ ____ Expiration Date: _______________________________ We will call you for the complete number. Authorized Amount: $_______________________ Card Holder Signature: ______________________________________________________________________ Card Holder Printed Name: __________________________________________________________________ Card Holder Tele: _________________________________________ Card Holder Email: ________________________________________________________________________ ASAP is not a government agency. ASAP is coded as a 'member services organization.' If your card is declined, 1) please ensure that you entered the activated card number and expiration correctly, and 2) check with your agency to see if the card is or can be authorized for our code. Most card holders have no issues once the code authorization is rectified. If you are using a travel card, it is highly unlikely that you can pay for a registration/tuition fee with a travel card. ASAP is incorporated in Washington, D.C. Federal Tax I.D. is 54-115-2815 DUNS is 184057818 SAM Cage # 1QTQ9.