Please complete the following registration form.

Organization

Full name

Title

Address

City

State

Zip

Phone

Alternate phone

Fax

Confirmation Email (if different)

Payment fees

$95 per person: Full Rally registration (includes dinner on Monday and lunch on Tuesday)

$25 per person: Lunch, Board of Directors meeting, and legislative issues brief only

$45 per person: Spouse/Guest for Monday night dinner

Name of guest

Payment Information

Name on Card

Amount to Charge

Credit Card Type

Credit Card Number

Expiration Date (mm/yy)

CCV Code

Cancellations and refund requests are subject to a non-refundable $25 administrative fee and must be requested in writing and received by FMEA before March 17, 2017. Refunds will not be made after this date. No-shows will not be refunded. All registration and payment information is for FMEA use only and kept strictly confidential.

Once your online application is received and your payment is successfully processed, you will be notified via e-mail.