Registration Form
Questions? Call NENA – 1-800-332-3911
NENA Membership Number |
____________ |
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Last Name |
Last ________________________________________ |
First _________________________________ |
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(as it should appear on your name badge) |
Title |
___________________________________________ |
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Agency/Company |
___________________________________________ |
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Address |
___________________________________________ |
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City, State/Province, Zip Code |
___________________________________________ |
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phone (work) |
Phone ___________________________________ |
Fax _______________________________ |
Home Phone (for emergency use only) |
Phone ___________________________________ |
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Attendee Information – Please circle just ONEin each section
Employer Category |
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01 9-1-1 Board |
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05 Consultant Services |
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09 Fire Department |
02 Government Board |
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06 Equipment Vendor/Distributor |
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10 EMS |
03 Telephone Company |
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07 Equip. Manufacturer/Developer |
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11 Other ______________ |
04 Independent System Provider |
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08 Police Department |
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12 Wireless Carrier |
Job Classification |
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01Director, Agency Head, Supervisor |
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06 Education & Training |
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11 Other ______________ |
02 Marketing/Sales |
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07 Emerg. Responder, Service Provider |
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12 9-1-1 Product Mgr. |
03 Project Engineer/Systems Designer |
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08 Dispatcher/Call Taker/Radio Opera. |
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13 County Elected Official |
04 DB Mgr./DB Developer/Addressing |
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09 Equip. Installation/System Install. |
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05 Data Base/Clerical |
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10 9-1-1 Coordinator |
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Registration Fees – Category & Cost
[ ] |
NENA Member * $295 |
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[ ] |
New NENA Members * $370 |
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[ ] |
Non-Members * $395 |
Each category includes: All educational sessions,registration materials, refreshment breaks & lunch.
“New NENA Member” also includes one-year NENA membership ($75).
Payment Information
_____ |
Check Enclosed, Payable to NENA (US Funds) |
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47849 Papermill Rd; Coshocton, OH 43812-9724 |
______ |
VISA |
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______ |
MasterCard |
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______ |
American Express |
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Credit Card Number |
__________________________________ |
Expiration Date __________ |
Signature |
__________________________________ |
Fax Completed Registration Form to (740) 622-2090 |
We Are unable to accept phone registrations.Cancellations received before November 20, 1998 will be charged a $25.00 fee.
No refunds can be given after November 20, 1998.
For NENA Use Only |
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Date |
___________ |
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Amount |
___________ |
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Ck/Auth |
___________ |