NPB Rep Registration Form
Please read and complete all necessary fields in each section of the registration form. Participants will be listed on the Attendee List within 72 hours of receiving the registration form.

First Name:
Last Name:
E-mail Address:
Office Address:
City:
State:	Zip:
Office Phone:
Name of Spouse/Guest, if applicable:
Is your Spouse/Guest a NPB Rep?	Yes No
Special Dietary Requirements:
Hotel Reservations
Hotel Required?	Yes No
Arrival Date:	Departure Date:
Special Room Requests :
King 2 Beds
Second Room Requested Yes Second Room Arrival Second Room Departure
Credit Card information required only if requesting 2nd room or additional nights Credit Card Type: AX MC VI Card Number: Expiration: Name on card:
Will you be attending the Welcome Dinner on Sunday, April 29th? Yes No (if yes, please select entree below) Entree Selection Beef Fish Chicken Vegetarian Entree Selection for guest (if applicable) Beef Fish Chicken Vegetarian
Assigned Sponsor Dine-around Monday, April 30th Will you participate in the "assigned" Sponsor Dine-around on Monday, April 30th? Yes No Will your Spouse/Guest attend the Dine-around? Yes No
Box Lunch on Tuesday, May 1st Would you like a box lunch on Tuesday, May 1st? Yes No Would your Spouse/Guest like a box lunch on Tuesday, May 1st? Yes No
Your Conference Confirmation will be emailed to you. Please look over your information and make sure you've filled out all the relevant fields correctly. If your name does not appear on the attendee list within 72 hours we did not receive your registration.