EPA 2021 Virtual Convention Registration Form

Contact Name*
First Last
Contact Phone*
Contact Email*
Enter Email Confirm Email
Publication Title
If you are representing a publication, enter the title. Otherwise, leave blank.
Organization/Company
The organization or company you represent. If none, leave blank.
List Each Person Registering*
This list must include each person, including yourself if applicable, who is registering for the convention. Email addresses must be included and must be unique to each person. Click the plus sign to add more lines (max. 15).
First Name Last Name Email Address Job Title
Are you an EPA member?*
If you are representing a publication or organization, is the publication or organization a current EPA member? If you represent yourself as an individual, are you a current EPA associate member?
- Yes
- No
Total Number Registered (Member)*
Please choose the total number of people registered above.
Total Number Registered (Non member)*
Please choose the total number of people registered above.
Promo Code
If you have a promo code, enter here.
Name of College
If you are using the student discount, please enter the name of your college or university
$50 Discount
$100 Discount
MTI International Discount
MTI US Discount
HACWN Discount
Total
$0.00
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Credit Card Billing Address*
Street Address City State / Province / Region ZIP / Postal Code Country
POLICIES AND CONDITIONS: By submitting this registration form, you are agreeing to the following:
CANCELATION POLICY: Cancelations by April 23, 2021, will receive a full refund. There will be no refunds after April 23, 2021.
CONTACT CONSENT: By registering for this event, you agree to be contacted by EPA with important information about this event and by its sponsors. You will have the option to unsubscribe at any time.

First Name	Last Name	Email Address	Job Title

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EPA 2021 Virtual Convention Registration Form