Company
Name:
Contact
Name:
Contact
email:
Address:
State:
Zip:
City:
Check here if first time attendee
1.
Name
Title:
email:
Phone:
Check here if first time attendee
2.
 Name:
Title:
Phone:
email:
Check here if first time attendee
3.
Name:
Title:
email:
Phone:
Check here if first time attendee
4.
Name:
Title:
Phone:
email:
If new attendee, provide name of person who referred you to our conference
Total # registering
Grand Total Due:
Check here if you will be mailing a check for payment.  Address is on the left.
Check here if making a credit card payment. Payment link is on the home page.
Photo Release
I/We hereby give the Utility Payment Conference and its delegated representatives the
permission to photograph me alone and/or with other attendees in conjunction with and
for the conference.  I/We understand the pictures may be used for the promotion of the
conference.  Publications of photographs shall include, but is not limited to, the
conference website, future conferences, promotional brochures and flyers and other
forms of media.
Liability Release Waiver Information
My/Our registration indicates I/We agree to release the Utility Payment Conference and
hotel, and each of their respective officers, directors, agents, representatives, and
employees (referred to collectively as "Releasees") from any and all claims, actions,
damages and liabilities, injury or loss that in any way are caused by, arise out of or result
from my participation in the Utility Payment Conference.
Cancellation and Change Policy
My/Our submitted registration form indicates I/We have read, understand and agree to the
conference Cancellation and Change Policy.  
Hotel Reservation Release
I/We hereby give the Utility Payment Conference and its delegated representatives
permission to inquire of the hotel information regarding my booked reservation.  In
addition, the conference hotel(s) has my/our permission to disclose my/our reservation
information to the conference's delegated representation.
List the information for each person registering for the conference.  Cost is per person for company
employee only.  Pay on/by June15 $425, pay on/by July 15 $525,  pay on/by August 15 $625
Submit this form electronically, then pay by credit card or mail your check to the address listed to
the left of this page.

Join Us!
www.paymentconference.com
Utility    
Communications, Cooperatives,
Municipalities and Utilities
Mail check to:    
Rose Clemensen
2608 E. Standish Ave.
Anaheim, CA 92806

Issue U.S. Funds check to:
Utility Payment Conference

Questions?

Call:
Rose Clemensen
714-774-4171  Office (PST)
714-743-0031  Mobile

Amanda Johnson
309-762-2854  Office (CST)
309-558-9588  Mobile

Email:
info@paymentconference.com