SMSA Conference - Online Registration Form

National Motorcycle Safety Conference
August 21-23, 2009
Madison, Wisconsin
SMSA Federal I.D. # - 31-128-5245

« Click here to review planned agenda and workshop descriptions.

Use one form per person; upon submission you will have the option to return and submit another
(i.e. for other staff members).

If you experience any difficulties using a government issued credit card,
please contact your credit card company directly.

Name:
Nickname (used for name tag):
Title (used for name tag):
Representing:
Mailing Address:
City:
State:
ZIP:
Daytime Phone:
Fax:
E-Mail:
Please indicate below all events you will attend. Any items not checked will be on your own. Tickets will be issued at the conference (Tickets cannot be guaranteed for those who register after August 1, 2009!)

Friday SMSA Business Meeting Lunch
This lunch is not included in the conference registration fee. All Business Meeting attendees & their guests attending this function will be charged $10 each. No lunch tickets will be available for sale on-site.
	SMSA Business Meeting Lunch - Self - $10 each
	SMSA Business Meeting Lunch - Guest - ($10)
	SMSA Business Meeting Lunch - 2nd Guest - ($10)
	SMSA Business Meeting Lunch - 3rd Guest - ($10)
	SMSA Business Meeting Lunch - 4th Guest - ($10)

Friday Afternon - PDW's
	Yes, I would like to attend the Professional Development Workshop - PDW Your Comprehensive State Motorcycle Safety Program Check if you plan to attend for Administrators - N/C
	Yes, I would like to attend the Professional Development Workshop - PDW Media Training Check if you plan to attend for Administrators and Instructors/RiderCoaches - N/C
	No, I am not planning to attend either Professional Development Workshop - PDW

Friday Evening - Instructor Appreciation
	Reception - Self - N/C
	Reception - Guest - $15 each
	Reception - 2nd Guest ($15)
	Reception - 3rd Guest ($15)
	Reception - 4th Guest ($15)

Saturday
	Lunch - Self - N/C
	Lunch - Guest - $20 each
	Lunch- 2nd Guest ($20)
	Lunch - 3rd Guest ($20)
	Lunch - 4th Guest ($20)

	Evening Event - Self - N/C
	Evening Event - Guest - $25 each
	Evening Event - 2nd Guest ($25)
	Evening Event - 3rd Guest ($25)
	Evening Event - 4th Guest ($25)

Sunday
	Lunch - Self - N/C
	Lunch - Guest - $20 each
	Lunch - 2nd Guest ($20)
	Lunch - 3rd Guest ($20)
	Lunch - 4th Guest ($20)

- Early registration deadline is July 21, 2009. - Late registration fee applies if postmarked after July 21, 2009.
	Registration Fee includes: Admission to conference activities, one t-shirt, one conference bag and meal functions for one person
	Please indicate your shirt size below:
	S M L XL XXL XXXL
	We cannot guarantee your shirt size will be available however; we will do our best to provide the requested size or the next larger size.
	*SMSA Member - Early Registration Fee - $170**
	Non-SMSA Member - Early Registration Fee - $195
	*SMSA Member- Late Registration - $195**
	Non-SMSA Member- Late Registration $220
Please select your membership category:
	I am not currently a member of SMSA (note: only current members are eligible for member rates)
	Voting Member (2 discounted registrations allowed for this membership category)
	Corporate Member (2 discounted registrations allowed for this membership category)
	Professional Member (2 discounted registrations allowed for this membership category)
	Supporting Associate Member (2 discounted registrations allowed for this membership category)
	Supporting Member (1 discounted registration allowed for this membership category)
	Emeritus Associate Member (1 discounted registration allowed for this membership category)

*SMSA Voting, Corporate, Professional and Supporting Associate Members are allowed up to two discounted conference registrations as a benefit of their membership. SMSA Supporting and Emeritus Associate Members are allowed one discounted conference registration as a benefit of their membership.

Only written refund requests will be considered.
A $25 processing fee will be deducted from all refunds.

No refund requests will be accepted after August 1, 2009.

SMSA Conference - Online Registration Form

Use one form per person; upon submission you will have the option to return and submit another(i.e. for other staff members).

If you experience any difficulties using a government issued credit card,please contact your credit card company directly.

Use one form per person; upon submission you will have the option to return and submit another
(i.e. for other staff members).

If you experience any difficulties using a government issued credit card,
please contact your credit card company directly.