Iowa-Illinois Safety Council - Your Safety & Health Leader

Iowa-Illinois Safety Council Registration Form

Company:
Contact Person:
Persons Enrolled:
Mailing Address:
Street Address (for UPS purposes):
City:	State: Zip: +
Phone:	( ) - xt.	Fax: ( ) -
E-mail:
County:		SIC Code:

Course Name and Date::


Please send an invoice for payment, I understand that until payment is received, I am not considered registered.



Cancellations without penatly may be made up to five working days prior to the conference date. Cancellation after that date will be charged 50% of the fee. You may avoid this charge by transfering registration to another person. Registrants who do not cancel are liable for the entire fee. All refunds will be in the form of a credit voucher. Please call 515.276.4724 if special accomodations are needed. Registrations are to be accompanied by the total payment. At this time we do not accept credit cards via the internet. That may be an option in the near future. However, if you are paying by credit card please print this registration form out, place your card number, name on the card and expiration date at the bottom and fax to: 515.276.8038. You may also submit the form for pre-registration. If paying by check please submit the form and mail your check indicating the date you registered on line. You may also submit this form for pre-registration and indicate if your company needs to be invoiced prior to payment, however in all cases, you will be considered registered when payment is received. Remit payment to: Iowa-Illinois Safety Council 8013 Douglas Avenue Des Moines, IA 50322-2453 Phone: 515.276.4724 Fax: 515.276.8038 E-Mail: iiscadmin@iisc.org