Company Information * Required fields *Company Name: *Address *City *State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming *ZIP Code *Email Conference Registration Full day, includes Awards Luncheon. EarlyBird After9/22 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 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 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 $