Registration Form

1. Job Title: (Check the onethat best describes your title)a. CEO/COO/President/Ownerb. Vice Presidentc. Directord. Consultante. Director of Safety or EHSf. Safety Consultant/Safety Engineerg. SHE, HSE, EHS Supervisor/Managerh. Safety Administrator/Coordinator/Committeei. Union Safety/CommitteeRepresentativej. Industrial Hygienistk. Facility Managerl. Risk Manager/Loss Control Managerm.Security Managern. Saleso. Skilled Tradespersonp. Other (please specify)____________________2. My Primary Areaof Expertise is: (Check one)a. Constructionb. Educator/Trainerc. Engineering/Designd. Environmental Protectione. Ergonomicsf. Fire Protectiong. Fleet Safetyh. HazardousWasteMaterialsi. Home & CommunitySafetyj. Human Resourcesk. Industrial Hygienel. Labor UnionRepresentativem.Occupational Safety,Health & Environmentn. Risk Management/Loss Control/Insuranceo. Safety Management/Administrationp. Safety Engineeringq. Studentr. Traffic/Highway Safetys. Other (please specify)__________________3. Years of Experiencein Field:(Check one)a. 1-3 yearsb. 4-9 yearsc. 10-19 yearsd. 20 or more years4. Age:a. Under 25b. 25 - 34c. 35 - 44d. 45 - 54e. 55 - 59f. 60 - 64g. 65+5. Gender:a. Maleb. Female6. Your Company’s IndustryAffiliation:(Check one)a. Aerospaceb. Agriculturec. Constructiond. Government/Public Administratione. Information Technologyf. Insuranceg. Manufacturingh. Miningi. Petrochemicalj. Professional Servicesk. Services (incl. health care)l. Trades (wholesale & retail)m.Transportationn. Utilitieso. Other (please specify)____________________7. Company Size: (Estimate ofemployees in all locations)a. 1 - 99b. 100 - 999c. 1,000 - 4,999d. 5,000+8. Purchasing Role:(Check one)a. Approve/Final Sayb. Specify Supplier/Vendorc. Recommendd. No Role9. Product Interest:(Check all that apply)a. Administrative/RiskManagement/Servicesb. Emergency Responsec. Environmental Protectiond. Ergonomicse. Facility Design,Maintenanceand Operationf. Fall Protectiong. General Safetyh. Hazard Controlsi. Home & Communityj. Industrial Hygiene/Occupational Healthk. Personal Protectionl. Securitym.Transportation10.Annual Planned PurchaseAmount:First Name Last NameCompany NameAddressCity State/Province ZIP/Postal CodeCountryPhone FaxE-mail3 WAYS TO REGISTER FOR CONGRESS:Check here if this is your first time EVER attending the NSC Congress & Expo.ONLINE: congress.nsc.org (preferred method)FAX: (708) 344-4444MAIL: NSC2013 Congress & ExpoP.O. Box 6271, Broadview, IL 60155Check here if, under ADA, you require special services in orderto attend. You will be contacted by NSC.FULL CONGRESS & EXPO (Includes access to the Opening and Closing Sessions,Keynotes, Rock ’n’ Community: Connections for a CauseTM, Technical Sessions, FREE EXPO ONLY (Includes access to the Opening and Closing Sessions, Rock ’n’ Community: Connectionsfor a CauseTM and the Expo floor for three days.)ONE DAY (Includes access to the Expo floor for one day.)Early Rate Advance Rate Standard Rate(By 6/28/13) (By 8/23/13) (After 8/23/13)NSC Member $555 $710 $800Non-Member $700 $875 $1000Government $555 $710 $800Student* FREE FREE FREEMonday Tuesday Neither DayEarly Rate Advance Rate Standard RateNSC Member $100 $150 $160Non-Member $150 $165 $175Distributor $125 $165 $17500008-35214. CONGRESS & EXPO FEES – For details, contact NSC Customer Service at (800) 621-7615.NSC1. REGISTRANT INFORMATION – No one under 12 years of age is permitted to attend the 2013 NSC Congress & Expo, regardless of affiliation.3. DEMOGRAPHIC INFORMATION – (Required)I am a member of the National SafetyCouncil. My NSC Member ID # is:I am NOT a member of theNational Safety Council.Not sure if your company is a member?Contact Customer Service at (800) 621-7619or customerservice@nsc.org.2. NSC MEMBERSHIP INFORMATION*Students must show proof of full-time student status and may not be employed as a full-time safety professional. Lunch is not included.REGISTRATION FORM(By 6/28/13) (By 8/23/13) (After 8/23/13)Title Cell/MobileCheck each day you plan to take advantage of the FREE Full Congress Lunch Voucher:One Day: M T W (Circle one) $75 $100 $100(Check one)a. Less than $10,000b. $10,000 - $24,999c. $25,000 - $49,999d. $50,000 - $99,999e. $100,000 - $499,999f. $500,000 - $1 Milliong. More than $1 Million11.Plan to PurchaseWithinthe Following Timeframe:(Check one)a. Immediatelyb. 1-6 monthsc. 7-9 monthsd. 10-12 monthsFull Congress Lunch Voucher, and the Expo floor for three days.)Source Code:Executive Edge workshops are available to Full Congress & Expo registrants only. You must attend Technical Session #44 – Executive Edge Panel: The Future of Managing Operational Risk in order to register for one or both workshops. Participation in the workshops is limited and available on a first-come, first-served basis. For more information, please visit congress.nsc.org. Code Executive Edge Workshops Rate45 Workshop A – What You Don't Know You Don't Know $9968 Workshop B – Big Data, Small Planet $99Registration Item Amount$Executive Edge Workshops (Section 5) $$$$$$Total Registration Fees $10. REGISTRATION SUMMARY5. EXECUTIVE EDGE WORKSHOPS6. PROFESSIONAL DEVELOPMENT SEMINARS7. ADDITIONAL OPTIONS8. NSC DIVISION/SECTION MEETINGSCode Division/Section Meeting Rate*306 Labor Division Meeting (Union Members only) $215307 Labor Division Spouse/Guest (Reception only) * $30308 Labor Division Spouse/Guest (Lunch only) * $45309 Labor Division Spouse/Guest (Reception & Lunch) * $75322 Construction Division Meeting and Reception $100323 Utilities Division Award Dinner (Members Only) $100324 Utilities Division Awards Dinner Spouse/Guest* $100The National Safety Council is a not-for-profit, 501(c)(3) organization. All gifts are tax deductible according to IRS regulations. No goods or services were provided in exchange for this donation. (FEIN#36-2167809)9. NSC FRIENDS OF SAFETY DONATIONYour support of the Friend of Safety Campaign is critical in enabling NSC to keep more people safe through greater education and awareness of safety practices at work, at home and on the road. As we look to the future of safety, join us as we address challenging issues like distracted driving, safety in the home and community, prescription drug overdose and workplace safety through the Journey to Safety Excellence. To learn more, visit nsc.org.$25 $50 $75 $100Admission to the NSC Congress & Expo requires an additional fee.Early Rate Advance Rate Standard RateNSC Member/ Non- NSC Member/ Non- NSC Member/ Non-Session Government Member Government Member Government Member(By 6/28/13) (By 8/23/13) (After 8/23/13)201 $900 $1,100 $1,000 $1,200 $1,100 $1,300 202 $900 $1,100 $1,000 $1,200 $1,100 $1,300 203 $300 $375 $350 $425 $400 $475 204 $300 $375 $350 $425 $400 $475 205 $300 $375 $350 $425 $400 $475 206 $350 $425 $400 $475 $450 $525 207 $300 $375 $350 $425 $400 $475 208 $300 $375 $350 $425 $400 $475 209 $300 $375 $350 $425 $400 $475 210 $300 $375 $350 $425 $400 $475 211 $300 $375 $350 $425 $400 $475 212 $300 $375 $350 $425 $400 $475 213 $300 $375 $350 $425 $400 $475 214 $300 $375 $350 $425 $400 $475 215 $300 $375 $350 $425 $400 $475 216 $300 $375 $350 $425 $400 $475 217 $300 $375 $350 $425 $400 $475 218 $275 $325 $275 $325 $275 $325 219 $650 $800 $700 $850 $800 $995 220 $650 $800 $700 $850 $800 $995 221 $300 $375 $350 $425 $400 $475 222* $300 $375 $350 $425 $400 $475 223 $300 $375 $350 $425 $400 $475 224 $300 $375 $350 $425 $400 $475 225 $300 $375 $350 $425 $400 $475 226 $300 $375 $350 $425 $400 $475 227 $300 $375 $350 $425 $400 $475 228 $300 $375 $350 $425 $400 $475 Cancellation PolicyCancellations received in writing on or before Friday, August 30, 2013, will be refunded lessa $100 processing fee. Cancellations received after Friday, August 30, 2013, are non-refundable.Donations to Friends of Safety are non-refundable. All cancellation requests should be sentto the National Safety Council, ATTN: Congress Refunds, via fax (630) 285-0798 or e-mail atcongressrefunds@nsc.org.Privacy StatementAll contact information will be used for NSC business purposes only. We will not misuse yourinformation. All correspondence will be e-mailed or mailed to the address on the registrationform. The registration mailing list is made available to exhibitors only.Program DisclaimerNSC will make every effort to avoid changes to the program and events; however, some changes may occur due to unavoidable circumstances.*Spouse/Guest name:___________________________________________________*You must pass the ASP fundamentals exam prior to taking the CSP fundamentals exam. *NSC Congress & Expo admission is not included. No Division/Section meetings will be held at McCormick Place West. For more detailed meeting information and locations, please visit congress.nsc.org.NSC Congress & Expo (Section 4)Professional Development Seminars (Section 6)NSC Division/Section Meetings (Section 8)National Awards CelebrationThis will be held Tuesday, October 1, from 5:30 p.m. to 8:00 p.m. in the Skyline Ballroom at McCormick Place West.# of tickets _______ x $75/ticket = $ __________Technical Tour – Soldier Field and SAFETYThis will be held Wednesday, October 2 from 9:30 a.m. – 11:30 a.m. and again from 1:00 p.m. – 3:00 p.m. Available to Full Congress & Expo registrants only. Limited seats available. # of tickets _______ x $30 per ticket. Limit 1 = $ __________Off-the-Job LuncheonThis will be held Monday, September 30 from 11:30 a.m. - 1:30 p.m. in room W476 at McCormick Place West.# of tickets _______ x $35/ticket = $ __________Check #____________ (payable to National Safety Council)U.S. Government Purchase Order (must be enclosed)AmEx Discover MasterCard VISACard Number Exp. DateSignaturePrint Name as it appears on cardNSC Friends of Safety Donation (Section 9) $Technical Tour (Section 7)NSC National Awards Celebration (Section 7)Off-the-Job luncheon (Section 7)333 Construction Division Networking Reception Only $60chapleaujTypewritten TextCEWEB Name: Phone/Fax: Title: Cell: Company: Email: Address: First time: Address 2: Country: ADA: Member: 0: Nonmember: NSC Member ID is: Demo: 0: 1: 3: 1: 0: 2: 0: 2: 1: 1: 3: 1: 0: 2: 2: 0: 2: 1: 3: 1: 0: 2: 2: 0: 3: 1: 3: 1: 0: 2: 2: 0: 4: 1: 0: 3: 0: 2: 1: 5: 1: 0: 2: 3: 0: 2: 1: 6: 1: 2: 3: 0: 2: 1: 0: 7: 1: 2: 3: 0: 1: 2: 0: 8: 1: 2: 3: 0: 1: 2: 0: 9: 1: 2: 3: 0: 1: 2: 0: 10: 1: 2: 3: 0: 1: 2: 0: 11: 1: 2: 3: 0: 1: 0: 12: 3: 0: 1: 1: 2: 0: 13: 3: 0: 1: 1: 2: 0: 14: 3: 0: 1: 1: 0: 15: 0: 1: 0: 1: 2: 3: 3: 0: 0: 1: 1: 0: 1: 2: 0: 3: 0: o Other pleasespecify: p Other pleasespecify: s Other pleasespecify: NSCMember: 0: 1: NonMember: 0: 1: Government: 0: Student: Monday: 0: 1: 2: 3: 301: 0: 302: 303: 304: 317: 318: Spouse/Guest: 201: 25: 0: 50: 75: 100: 202: 203: 204: 205: 206: 207: 208: 209: 210: 211: fill_51: 212: fill_53: 213: fill_55: 214: fill_56: 215: fill_57: 216: fill_58: 217: 218: fill_61: 219: 220: Check: 221: Purchase Order: 222: 223: Amex: Discover: MasterCard: VISA: 224: 225: Card Number: 226: Print Signature: Distributor: 1: 319: 227: 228: 45: 68: Tickets for the NationalAwards Celebration Receptionare 75each ticket: x 75ticket: x 30ticket: Technical Tour - Soldier Field and SAFETY $30 Per Ticket Limit 1: Off-the-Job Luncheon $35 each Ticket: x 35ticket: fill_59: fill_60: