API Tanker Conference 2012 - Future Leader Registration Form

Future Leader Registration Form API 2010 Tanker Conference May 21-22, 2012 Waldorf Astoria Orlando, Florida USA Registration Deadline May 11, 2012 fax your completed form to 202-682-8222 Please use a separate form for each attendee. Photocopies are welcome. Note: This is how your badge will read. Please print or type clearly. Name Nickname Job Title Company/Organization Mailing Address City State/Province Zip/Postal Code Country Phone E-mail SPONSORED BY: (Required information – If you do not have an e-mail address, please write in NONE) Spouse/Guest: Name Nickname Emergency Information/Special Needs: In case of emergency, contact: Name Relationship Day Phone Evening Phone If you have special needs (physical or dietary) that need to be addressed for you to fully participate, please indicate them here: Registration Fees (in U.S. Dollars) Must register by May 11, 2012 Future Leader ? $ 200 Method of Payment For faster processing, register online at www.api.org/meetings, or you may fax completed form with credit card payment information to 202-682-8222. No cover sheet necessary. By Credit Card – Please charge the following card: ? VISA ? MasterCard ? American Express ? Diners Club Card Number Exp. Date Cardholder’s Zip Code Print Cardholder’s Name Signature By Check – Please make sure your check is payable to the American Petroleum Institute and indicate the following reference number on the check to ensure payment is credited properly: SS-2300-MM003-7410. Mail the check with your registration form to: American Petroleum Institute, P.O. Box 1425, Merrifield, VA 22116-1425. May 21-22, 2012 Waldorf Astoria Orlando, Florida USA (Required information – If you do not have an e-mail address, please write in NONE)