2017 Midwest WITH CC

2017 Midwest Regional Conference on Lead and Healthy Housing

October 3 & 4, 2017

St. Louis - Downtown

Secure Registration Form

Credit Card Required

* Most fields are required

Full name

First name
(as preferred for badge)

Title

Company/Organization

Address
(where credit card is authorized)

City

State

Zip

Phone

Fax

Number of attendees

Registration Rates

For those registering between now and September 15, 2017

After September 15th, registrations increase by $25 per person.

Number Attending	Fees
For 1 person from an organization	$225
For 2 or 3 persons from an organization	$200 per person
For 4 or more persons from an organization	$175 per person

Payment Amount
(to be charged)

Credit card number

Card Code (CCV) - Typically on back of card

Exp Month (Numeric)
example 01 = January

Exp Year (Numeric) example 2013

Name on card

REGISTRATION CANCELLATION POLICY: Cancellations must be in writing. Refunds will be given to all requests received up to 72 hours before the first day of the conference, less a $45.00 cancellation fee. No refunds will be given for “no shows”.