Conference Form

Personal Information

Name

Service

Address

City

State

Zip

Day Phone

Cell Phone

Would you like an email confirming your registration?  Yes No
Email:

Would you like an email copy of your receipt?  Yes No
Email:

Conference Fees

One Day

Two Days

Sessions

Which sessions are you most likely to attend; note, you will be able to choose either session upon arrival. This information will be utilized for planning purposes only.

Friday

Session

Session

Session

Session

Saturday

Session

Session

Session

Session

 

Payment

Please mail cash or check to: Greater NW EMS, 2300 24th St NW, Suite 103, Bemidji, MN 56601 OR call 218-556-5137 with your credit card information.

Payments received after September 18 will be assessed the $30 late fee, even if the registration form has been received!

How will you be paying?

Please enter your PO number if paying through purchase order.