2019 Office Professionals' Seminar Registration Form

• Name*
  First Last
• Job Title*
• Is spouse attending?*
  Spouse attendance is INELIGIBLE for MoDNR re-cert hours. Spouses signing roster for credit without paid registration will be billed full member rate.
  • YES
  • NO
• Spouse Name*
  Enter spouse name as you wish it to appear on nametag.
  First Last
• System Representing*
• Billing Address*
  If paying by debit/credit card, the address MUST match the address associated with the card.
  Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code
• Mailing Address*
  • Same as Billing Address
  • Different than Billing Address
• Street Address (Mailing)*
• Address Line 2 (Mailing)
• City (Mailing)*
• ZIP Code*
• Phone*
• Email*
• IF YOU ARE USING BLUE VOUCHERS TO PAY FOR REGISTRATION,

  YOU MUST SIGN THE DAILY ROSTER REGARDLESS OF YOUR CERTIFICATION STATUS.

  FAILURE TO DO SO WILL RESULT IN YOUR SYSTEM BEING BILLED FOR REGISTRATION.

• Membership Status/Payment Type*
  Please select your membership/payment combination. (Regulatory agencies receive the member rate. This DOES NOT apply to water/wastewater systems owned/operated by a governmental entity.
  • Member - Debit/Credit - $190.00
  • Non-Member - Debit/Credit - $375.00
  • Member - BLUE VOUCHER - $190.00
  • Non-Member - BLUE VOUCHER - $375.00
  • Member - Check/Money Order - $190.00
  • Non-Member - Check/Money Order - $375.00
• Please mail check/money orders or BLUE Vouchers/Voucher Forms to:

  MRWA

  901 Richardson Drive

  Ashland, MO 65010

• Total
  $0.00
• Credit Card
  ATTENTION: TO AVOID THE POSSIBILITY OF DUPLICATE CHARGES, DO NOT "GO BACK" OR REFRESH YOUR BROWSER AFTER HITTING THE SUBMIT REGISTRATION FORM BUTTON.
  American Express

  Discover

  MasterCard

  Visa

  Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date   Security Code Cardholder Name