Registration Form
Questions? Call NENA – 1-800-332-3911
| NENA Membership Number | ____________ |
ATLANTA |
| Last Name | Last ________________________________________ | First _________________________________ |
| (as it should appear on your name badge) | ||
| Title | ___________________________________________ | |
| Agency/Company | ___________________________________________ | |
| Address | ___________________________________________ | |
| City, State/Province, Zip Code | ___________________________________________ | |
| phone (work) | Phone ___________________________________ | Fax _______________________________ |
| Home Phone (for emergency use only) |
Phone ___________________________________ |
Attendee Information – Please circle just ONEin each section
| Employer Category | ||||
| 01 9-1-1 Board | 05 Consultant Services | 09 Fire Department | ||
| 02 Government Board | 06 Equipment Vendor/Distributor | 10 EMS | ||
| 03 Telephone Company | 07 Equip. Manufacturer/Developer | 11 Other ______________ | ||
| 04 Independent System Provider | 08 Police Department | 12 Wireless Carrier |
| Job Classification | ||||
| 01Director, Agency Head, Supervisor | 06 Education & Training | 11 Other ______________ | ||
| 02 Marketing/Sales | 07 Emerg. Responder, Service Provider | 12 9-1-1 Product Mgr. | ||
| 03 Project Engineer/Systems Designer | 08 Dispatcher/Call Taker/Radio Opera. | 13 County Elected Official | ||
| 04 DB Mgr./DB Developer/Addressing | 09 Equip. Installation/System Install. | |||
| 05 Data Base/Clerical | 10 9-1-1 Coordinator |
Registration Fees – Category & Cost
| [ ] | NENA Member * $295 | [ ] | New NENA Members * $370 | [ ] | 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) | 47849 Papermill Rd; Coshocton, OH 43812-9724 |
| ______ | VISA | ______ | MasterCard | ______ | American Express |
| 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 | Date | ___________ | Amount | ___________ | Ck/Auth | ___________ |