Registrant Information First Name: [Required] Last Name: [Required] Title: Affiliation: City: [Required] State or Province (Select other if international): [Required] Select State or Province (Select other if international) AAA All USA States Only AAB All Canadian Provinces Only AB AK AL AR AZ BC CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MB MD ME MI MN MO MS MT NB NC ND NE NH NJ NL NM NS NT NV NY OH OK ON OR Other PA PE PQ PR RI SC SD SK TN TX UT VA VI VT WA WI WV WY YT Phone: [Required] Email: [Required] Participants will receive a flash drive that will contain the agenda, program, participant list, and handouts. The agenda and program will also be available in print. If you need an alternate format, please select one preference below: Material Format: Select Material Format Braille Electronic Large Print Do you have any dietary restrictions?: [Required] Select Do you have any dietary restrictions? Yes No If yes, please specify: Is there anything else we should know about your conference accessibility needs? Please let us know and we'll do our best to accommodate you. Do you have any accessibility concerns? Select Do you have any accessibility concerns? Yes No If yes, please specify: AFB Leadership Conference Registration Fees Conference Fees One day: $150 (After January 24 $175) Two days: $250 (After January 24 $300) Three days: $300 (After January 24 $350) Please select the days you plan to attend: Thursday, February 27: [Required] Select Thursday, February 27 Yes No Friday, February 28: [Required] Select Friday, February 28 Yes No Saturday, March 1: [Required] Select Saturday, March 1 Yes No If you have a discount code, please enter it here: Access Awards and Migel Awards No charge for these events. The Access Awards will take place the afternoon of Friday, February 28. Do you plan to attend the Access Awards on Friday afternoon?: [Required] Select Do you plan to attend the Access Awards on Friday afternoon? Yes No Do you plan to attend the Migel Luncheon on Saturday, March 1?: [Required] Select Do you plan to attend the Migel Luncheon on Saturday, March 1? Yes No Your registration fee includes the following meal functions: Access Awards reception on Thursday evening (consisting of light hors d'oeuvres) Migel Awards luncheon on Saturday Payment Through Purchase Order or Check Checks: Please make checks payable to the American Foundation for the Blind (AFB Leadership Conference). Purchase Orders: State agencies may use a purchase order if necessary.
If you have chosen to pay by check or purchase order, please print out this page and mail it in with your payment. We will send a confirming email once the payment process is complete. You may combine multiple participants onto one check or purchase order but please print out a separate registration form for each person. We will send an invoice for those sending purchase orders. If you have any questions, contact Heidi Walters by e-mail at email@example.com. Do you want to pay by purchase order or check? [Required] Select Do you want to pay by purchase order or check? Yes No If you have selected to pay by purchase order or check, please skip the credit card section below, and go right to the Continue button. Please Provide Your Credit Card Information Card Type: Select Card Type American Express Visa MasterCard Discover Card Number : Expiration [mm/yy]: First Name on Card: Last Name on Card: Verification Number: The verification number is a 3-digit number printed on the back of your card. The American Express verification number is a 4-digit number printed on the front of your card. Credit Card Address Line 1: Address Line 2: City: State or Province (Select other if international): Select State or Province (Select other if international) AAA All USA States Only AAB All Canadian Provinces Only AB AK AL AR AZ BC CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MB MD ME MI MN MO MS MT NB NC ND NE NH NJ NL NM NS NT NV NY OH OK ON OR Other PA PE PQ PR RI SC SD SK TN TX UT VA VI VT WA WI WV WY YT Zip Code: Country: Select Country United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Apo Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegowina Botswana Bouvet island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'ivoire Croatia (local name: Hrvatska) Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe islands Fiji Finland Fpo France France, Metropolitan French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard and Mc Donald Islands Honduras Hong kong Hungary Iceland India Indonesia International Iran (Islamic Republic of) Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao, People's Democratic Republic of Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia, The Former Yugoslavia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadin Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia (Slovak Republic) Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sa Spain Sri Lanka St. Helena St. Pierre and Miquelon Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Tanzania, United Republic of Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City State (Holy See) Venezuela Vietnam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Islands Western Sahara Yemen Yugoslavia Zaire Zambia Zimbabwe You will have a chance on the next page to confirm your purchase. You must hit "continue" in order to complete your registration. After your registration is complete, you will receive an e-mail from AFB, which will serve as your receipt. If you have any concerns, or if you do not receive the e-mailed receipt, please contact Heidi Walters by e-mail at firstname.lastname@example.org. * Cancellation Policy: In the event that you need to cancel your registration, you must cancel by February 14, 2014, for a full refund.