|
10th Biennial Dominick F. Barbera EMS
Conference
Registration: $375
Founders Circle Registration: $375
Leadership Trust Registration: $500
The Fontainebleau Miami Beach Hotel
4441 Collins Avenue
Miami Beach, FL 33140
(800) 548-8886
IAFF Federal ID No.
53-0088290
EMS Conference registration
is no longer available online. You may still register onsite
at the conference beginning June 6. We look forward to
seeing you in Miami!
REGISTRATION FEE
CANCELLATION/REFUND POLICY:
Your registration fee
will be cancelled and refunded before May 22, 2009. Any
request for refund must be made in writing and sent to the
IAFF, Attn: Beverly Lewis, 1750 New York Avenue, NW,
Washington, DC 20006 or via fax at (202) 783-4570. Paid
registrants who cannot attend the Conference due to an
unforeseen event must request a refund in writing by July
15, 2009. No refunds will be issued after that date.
FIREPAC CONTRIBUTION:
Become a FIREPAC Leadership
Trust or Founder’s Circle member and automatically register
for the EMS Conference in one easy step. The FIREPAC option
is only available to IAFF members. Federal election law
prohibits the solicitation of non-IAFF members. IAFF members
selecting the FIREPAC option must submit his/her own
personal check or use his/her own personal credit card.
Federal election law prohibits FIREPAC from accepting union
or corporate money. One person cannot write a personal check
or use a personal credit card to cover multiple registrants
contributing to FIREPAC. Contributions to FIREPAC are not
tax deductible.
1) FIREPAC Leadership Trust ($500 and above
contribution)
2) FIREPAC Founder’s Circle ($375)
-
U.S. MEMBERS: Make
your personal, voluntary contribution of $500
(personal check, money order or credit card)
payable to FIREPAC. One registration form per
individual.
-
CANADIAN MEMBERS:
Make your personal, voluntary contribution of
$500 (USD) (personal check, money order, or
credit card) payable to FIREPAC Canada.
One registration form per individual.
All members of FIREPAC’s Leadership Trust ($500) and
Founder’s Circle ($375) will receive a specially
designed pin.
If, paying by credit card: Personal VISA OR
MasterCard (circle one)
Name on credit
card________________________________________
Expiration Date: ___________________________
Signature: ________________________________
(Click here for a
downloadable form)
Copy this form if necessary.
One form per registrant please.
PARTICIPANT(S)
ATTENDING: Please MAIL or FAX Registration
CONTACT INFORMATION:
NAME:_________________________________________________
ADDRESS:
______________________________________________
EMAIL:______________________________ Local
#:_________________
IAFF MEMBER # (does not apply to
Guest):___________________________
TITLE: ___ President
___ Vice President ___
Secretary-Treasurer
___ Executive Board ___
Member ___ Guest
*All guests must be invited by the IAFF local
affiliate president.
METHOD
OF PAYMENT:
_____ Check/Money
Order (FIREPAC
contributors payable to IAFF FIREPAC;
all other made payable to: IAFF EMS Conference)
_____ Purchase Order
No. _________________
(include copy of P.O.,
if possible)
Address for sending
invoice to process the Purchase Order (if different
from the registrant
and address above):
____________________________________________________
____________________________________________________
_____ VISA OR
MasterCard (circle one)
(If IAFF member and
contributing to
FIREPAC, see FIREPAC Contribution section for
further direction.)
Name on credit
card_______________________________________
Card
No._______________________________________________
Expiration Date: __________________________
PARTICIPANT
WORKSHOP SELECTION:
From the list/chart of
sessions provided, choose the six (6) sessions you
would most like to attend. Then select an alternate
choice. (Note: Space is limited and sessions will be
filled on a first-register basis. If you do not
complete this section, you will be randomly assigned
to available classes.
Participant
Name:______________________
Workshop
Alternate
Session
I__________________________________
Choice_________________________
Workshop
Alternate
Session
II__________________________________
Choice_________________________
Workshop
Alternate
Session
III_________________________________
Choice_________________________
Workshop
Alternate
Session
IV_________________________________
Choice_________________________
Workshop
Alternate
Session
V__________________________________
Choice_________________________
Workshop
Alternate
Session
VI_________________________________
Choice_________________________
|
