Company Information
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*Company Name:
*Address
*City
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*ZIP Code
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Conference Registration
Full day, includes Awards Luncheon.

	Early Bird	After 9/22
Member (SDSC/SHRM/CASD)	$225	$250
Nonmember	$270	$295
Each attendee after first three	$150	$150
Are you a member? YES     NO

Conference Attendees

Attendee	Name	Email
1:
2:
3:
4:
5:
6:

Additional Luncheon Tickets
Includes admission to Awards Luncheon.

Choose how many 0 1 2 3 4 5 6 7 8 9

$35

$40

Payment Information

Card Type:	VISA MC AMEX
Name on Card:
Card Number:
Card Expiration:	Month 01 - January 02 - February 03 - March 04 - April 05 - May 06 - June 07 - July 08 - August 09 - September 10 - October 11 - November 12 - December     Year 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032

Card Authorization
By submiting this form, you authorize South Dakota Safety Council to charge the
included credit card for the selected items above.

I certify that my organization is tax exempt.

SubTotal $
Tax $
Total $