Company
Name:
 Contact
Name:
Contact
email:
Address:
Zip:
City:
State:
Check here if first time attendee
Title:
1.
 Name
email:
Phone:
Check here if first time attendee
2.
 Name:
 Title:
email:
Phone:
Check here if first time attendee
3.
 Name:
 Title:
email:
 Phone:
Check here if first time attendee
4.
 Name:
 Title:
email:
 Phone:
If new attendee, provide name of person who referred you to our conference
Total # registering
Total Amount Due:
Guest Registration (Spouse, significant other, sibling or parent ONLY)  $100 per person
Includes Welcome Reception and Conference Reception ONLY
1.
 2.
 Name:
Name:
Total # guests registering
Check here if you will be
mailing a check for payment
Total Amount Due:
Check here if you will be
paying by credit/debit card
Grand Total Due:
Registration Information
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
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 understand the conference Cancellation
and Change Policy and accept its' terms as follows:  
  • 100% refund provided until August 1
  • 50% refund provided until August 15
  • No refund effective August 16
  • A $75 processing fee will be applied to all cancellations.
  • An initial change fee will be waived.
  • Each additional change will incur an administration fee of $25.
  • A 5% charge each month will be assessed until paid in full.  
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.  Register by July 15 $350     September 1 $450       September 2 $550
Submit form electronically by credit card or mail check to address listed on left.
Questions? Call:
Rose Clemensen
714-774-4171  Office
714-743-0031  Mobile

Mail check to:    
Rose Clemensen
Utility Payment Conference
2608 E. Standish Ave.
Anaheim, CA   92806-4319

Note:  Check should be made
payable in U.S. Funds

Issue check to:
Utility Payment Conference