MsRWA Annual Conference – Attendee Registration Step 1 of 3 33% June 1-3 | Biloxi, MSWater/Wastewater System Attendee Name* First Last PositionWater CertYesNoCert #Expiration Date Date Format: MM slash DD slash YYYY Wastewater CertYesNoCert #Expiration Date Date Format: MM slash DD slash YYYY System/Company Name*PWS ID#Address* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone*FaxEmail* Registration Type*Full RegistrationBy The Day RegistrationOne Day Exhibit Hall PassFull Registration (Exhibit Hall Pass Included)*MsRWA System Member -$250Non-Member - $500 Per DayBy the Day Registration*(Fee is per Day)MsRWA System Member - $150 Per DayNon-Member - $300 Per DayWhich Day*Spouse Registration (Exhibit Hall Pass & Shrimp Boil/Fish Fry included)*Yes, Please add my spouse - $150No, I do not wish to purchase a spouse registration.Spouse Name for Badge* First Last One-Day Exhibit Hall Pass: Wednesday June 2nd (No CEU's Hrs)*There are no training hours with this pass.Member - $100Non-Member - $200Total $0.00 Golf & Clay Shoot Registration Fees(Participants must be registered for full conference, please fill out related forms)Golfing*Yes, We will participate in the golf tournament.No, we will not participate in golf tournament.Hole Sponsor*No, I do not wish to sponsor a hole -$0.00One Hole Sponsor -$250Two Hole Sponsor - $500Three Hole Sponsor - $750Number of Golfers*Golfer included in Hole SponsorOne Golfer $110Two Golfers $220Three Golfers $330Four Golfers $440Golfer's Name* First Last Golfer's Name* First Last Golfer's Name* First Last Golfer's Name* First Last Mulligans ($20/Each)No Mulligans1-Mulligan $202- Mulligans $403 - Mulligans $604 - Mulligans $805 - Mulligans $100Additional OptionsYes, I will be attending the Shrimp Boil/Fish Fry Tuesday at Point Cadet Pavilion, Biloxi, MS*Yes, I will be attending the Shimp Boil/Fish Fry - TuesdayNo, I will not be attending the Shimp Boil/Fish Fry - TuesdayHow many (Adults/Children over 5) will be attending the Shrimp Boil/Fish Fry with you?*Please only put additional tickets needed here! Do not count yourself (attendee). (Full Registration Attendees get 1 Shrimp Boil/Fish Fry ticket, Plus 2 Free Tickets for use for Adults/Children over 5 to accompany attendee.)0 - No one will accompany me to the Shrimp Boil.1 - One extra Shrimp/Fish fry Ticket - Adult/Child over 52-Two extra Shrimp/Fish fry Ticket - Adult/Children over 53-Three extra Shrimp/Fish fry Ticket - Adult/Children over 54-Four extra Shrimp/Fish fry Ticket - Adult/Children over 55 - Five extra Shrimp/Fish fry Ticket - Adult/Children over 56-Six extra Shrimp/Fish fry Ticket - Adult/Children over 57-Seven extra Shrimp/Fish fry Ticket - Adult/Children over 58-Eight extra Shrimp/Fish fry Ticket - Adult/Children over 59-Nine extra Shrimp/Fish fry Ticket - Adult/Children over 510-Ten extra Shrimp/Fish fry Ticket - Adult/Children over 5How many (Children under 5) will be attending the Shrimp Boil/Fish Fry with you?*Children under age of 5 are free, we just number for head count. Price: $0.00 Quantity: Donation to MsRWA Scholarship FundEnter donation amount (optional) Donation to MsRWA RWEAC (Rural Water Emergency Assistance Cooperative)Enter donation amount (optional) Preferred payment method*Pay online w/ credit cardMail a checkOtherTotal $0.00 CommentsThis field is for validation purposes and should be left unchanged.
