* = Required
Name*
Title
Company
Address*
City*
State*
Zip*
Phone*
Email (required for receipt)

Conference Registration Options
	Absolutely no refunds after October 1, 2010.
	Preconference Only		$130
	Conference Only		$199 Chapter Members and Affiliates $249 Others (includes Chapter membership through October 2010)
	Conference AND PreConference		$269 Chapter Members and Affiliates $375 Others (includes Chapter membership through October 2010)
	Conference Only - Students		$110
	Conference AND Preconference - Students		$180
	Fee for Academic Credit (In addition to the full conference price. This includes $55 PSU fee and $25 ASTD admin fee)		$75
	Lunch with Brad Barton on 10-20 (must also be registered for the conference - includes autographed copy of his book)		$35
	Lunch with Thiagi on 10-21 (must also be registered for the conference)		$35
Additional Conference Registration Information
	Demographic Information
	Completing the information below will assist the Chapter in building marketing materials for future events. This information is not identifiable to any person and will only be summarized for the entire conference. Completing or not completing this information will not affect your registration.
	Industry		Agriculture
	Select only ONE.		Banking, Finance, Insurance
			Business Services
			Communication
			Education / Government
			Healthcare
			Hospitality / Tourism
			Manufacturing / Construction
			Nonprofit
			Services (consulting, specialty firms)
			Technology
			Utilities
			Other (please list)
	Professional Role		Academician
	Select only ONE.		Training Coordinator
			Training Specialist
			Training Manager / Director
			Technical Trainer
			HR Specialist
			HR Manager
			Independent Consultant
			Internal Consultant
			OD Specialist or Manager
			Other (please list)
	Years in the T&D Field		0 - 2 Years
	Select only ONE.		2 - 5 Years
			5 - 10 Years
			10 or more

Enter Chapter Member Number
Discounted amounts are for Chapter Members / Local Affiliates / Regional Chapters only. National ASTD membership does not confer a discount. If you are from a local affiliate or regional chapter, you will need to secure the special code from your organization in order to automatically receive the discounted amount. Please email the ASTD office if you do not have your Chapter membership number.