​49th ANNUAL CONFERENCE
NATIONAL ASSOCIATION OF WOMEN HIGHWAY SAFETY LEADERS, INC.

Sheraton Seattle Hotel, Seattle, Washington
August 24-28, 2016     Register by July 22!

Conference Registration Form

Please print or type.  Be included in the Registry of Participants!  Complete this form and submit.

Name:______________________________________________________________

Organization:_______________________________________________

NAWHSL Position:________________________________________________________

Address:___________________________________________________________

City:___________________________State:__________Zip Code:_________

Telephone:________________FAX:______________Email:_________________

Meal Restrictions:__________________________Need exhibit space Yes______  No______

Emergency contact & phone:____________________________________________

Choose one of 3 ways to pay:
1.  Credit or debit card.
     Name on card _____________________________________________________________________
    
     Billing address_____________________________________________________________________
     Credit Card type (Please circle)   Visa       MasterCard        Discover

     Card Number______________________________________________________________________
     Expiration date______________________ Security digits on back____________________________

2.  Check or money order by mail with registration form payable to Ntl. Assoc. of Women Highway Safety Leaders  
3.  Purchase order and pay later.  PO#____________________________________________________________ 

SUBMIT FORM to Registration Director:  Judi Keippel  phone 773-278-8476   fax 773-278-7135
      judikeippel@yahoo.com   Send to 2743 N. Albany, Chicago, IL 60647


      Conference Registration includes all sessions, materials, and meals
Member
Non-Member
$250.00
$275.00
$____________
$____________
Member
Non-Member
$275.00
$300.00
$____________
$____________
 
Registration - After AJuly 22, 2016
Advanced Registration - Prior to July 22, 2016
      
      Total Due

Spouse/Guest (of registered attendee)
Saturday Night Banquet Only

 $75.00
$175.00
$____________
$____________
$____________