- Use this form to register when paying by Visa, MasterCard or American Express.
- Registration is $295 per person and includes access to all keynote sessions, breakout sessions, continental breakfasts, lunch and the evening cocktail party.
- Eight hours of continuing education (TX agents only) is available for those that fulfill the requirements (including signing in to sessions, filling out and turning in a survey at the end of each session, etc)
- All registrations will be confirmed via email.
- Registration is only good for 2009 Symposium, held September 15-16, 2009 in Dallas, TX.
- To register and pay by check, please download the registration form, fill it out and send it in with your check.
- A Registration received without payment will not be confirmed until payment is received.
- All Registrations are non-refundable.
- Questions? Contact 1-800-500-8720 x4256 or email info@einsurancesymposium.com
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Attendee Registration Information
(* Denotes Required Field) |
| *Attendee Name: |
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| *Job Title: |
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| *Company: |
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| *Email: |
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| *Phone: |
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| *Address: |
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| *Zip Code: |
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| *City: |
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| *State: |
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*Primary Contact:
(if different than primary attendee) |
Title:
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Additional Registrations |
You may register up to five additional registrations with this order. Each additional attendee registration is $295. MarketScout recommends
that you make all purchases in advance to avoid delays in entering the
exhibit hall. (Note: No one will be admitted to the exhibit hall without
a badge.)
Plese enter the name and title of each additional registration.
Additional Attendee:
Title:
Additional Attendee: Title:
Additional Attendee: Title:
Additional Attendee: Title:
Additional Attendee: Title:
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Spouse Registrations |
Spouses are welcome to join attendees at the Entrepreneurial Insurance Symposium. For a reduced rate ($175), your spouse can attend both breakfasts, lunch and the cocktail party. Spouse badges do not give access to any keynote or break out sessions or for the Networking Mall outside of meal times.
Plese enter the name of spouses that will be attending the Symposium.
Spouse:
Spouse:
Spouse:
Spouse:
Spouse:
Spouse:
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Coupon Codes |
If you have a coupon discount, please enter it here. Please remember that coupons are case-sensitive and must be entered in ALL CAPS.
Coupon Code:
Discount Amount.
X
=
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Enter your payment information below.  |
| * Card Type |
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| * Card Number |
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| * Expiration Date (MM/YY) |
Month:
Year:
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| * CVC Code |
(Security Code on the Back of Your Card) |
* Billing Address
Street Only |
(only allows 20 characters) |
| * Billing Zip |
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Cost Breakdown
Please review the cost breakdown below to make sure that you have registered the correct number of attendees and are receiving any coupon discounts you have applied to this order. Due to the number of registrations being processed, we are not able to offer retro-active discounts to attendee registrations.
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# of Additional Attendees:
# of Spouse Registrations:
Total Attendees:
TOTAL AMOUNT:
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By clicking this button, I authorize MarketScout to process my card for the above amount, shown in the "Total" box.
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MarketScout will send an email verification at the end of this form to serve as registration confirmation.
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