DATIA 2020 Annual Conference Pre-Registration Form

* required
Company Name* Registrant Name*
Address* City* State* Zip*
Phone* Fax Email*
Please indicate which industry segment you represent with the following options:

Employer
Product Manufacturer/Provider
Collection Facility
Consortium/TPA
Medical Review Officer (MRO)
Substance Abuse Professional (SAP)
Employee Assistance Programs (EAP)
Other

If Other, please specify
Please indicate any special dietary needs (food allergies, vegan, vegetarian, etc.)
PAYMENT MUST BE RECEIVED BY SEPTEMBER 30, 2019 TO QUALIFY FOR THESE DISCOUNTS
  Early Rate Registrant Name Registrant Email
DATIA 2020 Annual Conference Pre-Registration - Member A $100 savings off of the early bird rate and $200 off of the regular rate $349
DATIA 2020 Annual Conference Pre-Registration - Non-Member A $100 savings off of the non-member early bird rate and $200 off of the regular rate $599
DATIA 2020 Annual Conference Pre-Registration at Member Rate + Dues through 9/2020
A $100 savings off of the member early bird rate and $200 off of the member regular rate PLUS all of the benefits of DATIA membership for a year at only $45 (regularly $295)
$644

Payment Information
Total Due:$
Option 1: Pay By Check

To pay by check, please print this form and mail it to:

DATIA 1325 G Street NW
Suite 500 #5001
Washington, DC 20005

The total amount due on this form will be honored.

Registration is not complete until payment is received.


Option 2: Pay By Credit Card

Credit Card Type: MasterCard
Visa
American Express
Card #:
Expiration Date:


Type the code shown in parentheses (DATIA2020):

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