REGISTRATION Two options 1. Print and fill out form and send with check payment Registration Form PDF 2. Fill out form below and choose payment option CAPTASA Conference Registration Form CAPTASA Conference Registration Form January 24-25, 2020 Embassy Suites - Lexington, KY Contact Name * First Last * Last If registering for someone who's name is not on the redit care. Please, add their first and last name here. Contact Name * First Last * Last Profession/Credentials/None Name for Nametag * Institution/Organization/None Mailing Address * City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip * Phone Fax Email * Please list any special needs you may have (dietary, etc.): Payment Information • Cost of Banquet NOT included in registration fee. • No one day, group rate or scholarships $225 Early Registration Fee NO REFUNDS AFTER JANUARY 15, 2020 I plan to attend the banquet Friday night (cost $35) * Yes No # of guests @ $35 per ticket - Do not include yourself in this count. * # of Handouts @ $35 per set * MUST PRE-ORDER BY JANUARY 18 - NOT AVAILABLE FOR PURCHASE AT CONFERENCE - Handouts will be available online @ www.captasa.org for no charge. FOR EXPRESS REGISTRATION AT THE CONFERENCE: Print your receipt and bring it with you when you register in Lexington. Total Pay Now If you are human, leave this field blank.