Title Facility City, State Day, Date | Time RegistrantSalutation*Mr.Mrs.Ms.Dr.First Name*Last Name*Company*Job Title*Address*City*State*Zip/Postal Code*Country*Phone*CellFaxEmail* Email Notifications*Yes, I authorize receiving publication email notificationsNo, I would not like to receive publication email notifications (opt-out)Authorization for receiving publication email notifications from NWMOA. (applies to all email addresses on this form)Website Special Needs Food Allergies (describe in comments) Gluten Free Meals Halal Meals Vegan Meals Vegetarian Meals Wheelchair Access Other (describe in Comments) Member (check all that apply) NWMOA AMTA NWMOA - Membrane Operator TrainingWorkshop Registration*Members/Affiliates (must be from the list above), $150.00Non-Members - Certified Ops (includes 1 year Div 1B NWMOA Membership), $200.00Non-Members - Non-Cert. Ops (includes 1 year Div 3A NWMOA Membership), $225.00Non-Members - Non-Cert. Ops (includes 1 year Div 3C NWMOA membership), $275.00TESTING, $0.10For other types of membership - please contact NWMOA for membership application, or click here to apply for membership now. Contact Hours for Water/WastewaterContact Hours for Water/Wastewater, $25.00No Contact Hours RequiredLicense #*License State*License Type*License Grade* Total Registration Fee $0.00 Payment InformationPayment Method*Credit Card - Online PaymenteCheck (Bank Wire w/o processing fee) - Online PaymentCheckInvoiceIf paying by check: Make checks payable to: Northwest Membrane Operator Association (NWMOA) and mail to: 12592 West Explorer Dr., Ste. 200, Boise, ID 83713. CommentsIf you would like a copy of the invoice/receipt sent to another*Yes, send copy of invoice/receipt to:No, don't need a copy sentIf yes, you would like a copy of the invoice/receipt sent to another other than the attendee please enter information below.Name* First Last Email Address* Comments or Instructions before March 21, 2014 will receive a refund, less a $50 processing fee. Full payment is required if cancellation is received on or after March 22, 2014 - no refunds and no credits for future events will be granted. However, substitutions may be made at any time. NWMOA reserves the right to make changes in programs and speakers, or to cancel programs when conditions beyond its control prevail. Every effort will be made to contact each enrollee if a program is cancelled. If a program is not held, NWMOA’s liability is limited to the refund of the program fee only. CAPTCHAFinally, to prove you're human, enter the characters displayed below.Captcha