Louisiana rural water association

Attendee REGISTRATION FORM

(Please Print)

Attendee required INFORMATION

First Name: / Last: / Operator ID #:
Title/Position: / Last 4 Digits Social Security #:
System/Facility Name:
Mailing Address: / Phone #:
City: / State: / Zip: / Fax #:
Email Address for confirmation letter:
If spouse/companion or child(ren) will be attending conference please add their first & last names below (needed for name badges):

CLASSROOM REGISTRATION INFORMATION

Attendee registration includes the following: classroom instruction, breakfasts, lunches, dinners, exhibit hall viewing, all entertainment and one (1) awards luncheon ticket (Wednesday). Spouse/companion and/or child(ren) received all the same at no extra cost with the exception of classroom instruction and awards luncheon ticket. If spouse/companion and/or child(ren) wish to attend awards luncheon on Wednesday they must purchase a ticket; information below.
(place “X” in box next to class – choose only ONE (1) / Member / Non-Member
Provided the number of people, in box to left, listed on this form that will attend the FISH FRY on Tuesday 7/17/18 (no charge)
24 Hr Technical Training (all sessions approved for Water & Wastewater CEUs) / Tue/Wed/Thu 8am-5pm / $340 / $390
32 Hr Water Certification Levels 1 & 2 (P/T/D) / Mon/Tue/Wed/Thu
8am-5pm / $360 / $420
32 Hr Water Certification Levels 3 & 4 (P/T/D)
32 Hr Wastewater Certification Levels 1 & 2 (T/C)
32 Hr Wastewater Certification Levels 3 & 4 (T/C)
Option for 40 Hours this is ONLY for individuals that received a letter from LDH that states you need 40 hours of instruction to be eligible for the exam. Call LDH at 225-342-7508 if you have taken the exam 3 times and failed; this is an indication you could possibly need 40 hours. / $100
Members or Non-members
In box to left place the number of Extra Adult Award Luncheon Tickets if needed (age 14 and up) / $40
In box to left place the number of Extra Child Award Luncheon Tickets if needed (age 13 and under) / $15
$20 from this registration will be allocated to LRWA PAC funds

PAYMENT

Check/Money Order payable to: La Rural Water Association; Conference Department; PO Box 180; Kinder, LA 70648
Credit Cards accepted: Visa; Mastercard; American Express; Discover / 4% credit card convenience fee
Card Number: / Expiration Date:
Email for sending receipt: / Phone #:
Signature:
If paying by credit card fax form to secure fax number 337-738-5620

CANCELATION/REFUND POLICY

Written request for cancelation/refund must be received by fax (337-738-5620) or email () or mail prior to July 1, 2018.

$100 processing fee on all cancelations (replacements are welcome). No refunds for luncheon tickets.

NO refunds will be granted after July 1, 2018