Discounted College/University Student Conference Cost:  
By Day:  Monday; $50, Tuesday; $125, Wednesday; $125 or Thursday; $75
Entire conference: Monday - Thursday; $375
Check One:
 College Graduate or MBA
student
Senior
Junior       
College or
University:
Address:
State:
City:
 Zip:
Your Name:
Your Phone:
Your email:
Your major:
Graduation
date:
College ID #:
Professor's
Title:
Professor Name
Professor's
email:
Professor's
Phone:
Total Amount Due:
Check here if you wish to share a room
Check here if you will be mailing a check for payment. Mail address is to left.
Check here if you will be making a credit card payment.  Link is on Home page.
Check here if first time attendee
If new attendee, list name of person that referred you to the conference, if any.
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.
My Registration indicates I have read the Cancellation and Change Policy and agree to
the terms stated.  
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.
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 and hotel (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.
Code of Conduct Policy
My/Our submitted registration form indicates I/We have read, understand and agree to
the conference Code of Conduct Policy and accept its' terms.
Submit your registration electronically.  Next Mail your U.S. funds check to address listed to the left
or go to our Home page and pay by credit card.
Questions? Call:
Amanda Johnson
309-762-2854  Office (CST)
309-558-9588  Mobile
info@paymentconference.com

Mail check to:  
Utility Payment Conference  
Amanda Johnson
3522 - 33rd St. Ct.
Moline, IL 61265

Issue check to:
Utility Payment Conference

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