Testing – do not delete TEST Membrane Operator Certification Registration This form is for testing & development purposes only. RegistrantSalutation*Mr.Mrs.Ms.Dr.First Name*Middle InitialLast Name*Job Title*Company*Address*City*State*Zip/Postal Code*Country*Telephone*CellFaxEmail Address* Website Special Needs Food Allergies (describe in comments) Gluten Free Meals Halal Meals Vegan Meals Vegetarian Meals Wheelchair Access Other (describe in Comments) Communication and Data Sharing PreferenceNWMOA has been diligent in Data Security and being compliant with US and other Nations regulations in sharing your contact information as well as receiving email communications from NWMOA on upcoming events and other resources.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 notification from NWMOA. (applies to all email addresses on this form)Data Sharing*Opt-In: It is ok to share my contact information (name, job title, company, address, email, phone, etc.) with NWMOA Board, Event Sponsors, Speakers, Moderators & Attendees.Opt-Out: Do not share my address, email or phone. Outside of NWMOA Administration, only my name, title and company will be shared with NWMOA Board, Event Sponsors, Speakers, Moderators & Attendees License #License StateLicense TypeLicense Grade Membrane Operator CertificationThe registration fee includes CEUs/PDHs, the shipment of the MOC Manual to the address listed above upon receipt of full payment. If an alternate address for shipment is requested, please provide the preferred shipping address in space provided below. For payments received within five (5) business days of the school, the MOC Manual will be provided on the first day of class.Limited Space - Registration Reserved ONLY Upon Receipt of Payment and AvailabilityMOC Registration (Nov. 6‐8)*NWMOA Members, $350No Class RequiredMembership is required to attend this short school. If you are not a Member, click here: membership application.MOC Exam Registration (Nov. 8)*Exam, $25No Exam RequiredTo be certified, exam is required and exam fee is not included with registration feeShipping MOC Manual to a different address?*Yes, Ship to a different address than listed aboveNo, Ship to the same address listed aboveAlternate Address for the Delivery of the MOC Manual: If the shipment of the MOC Manual is to an alternate address, please provide it here. Please note that a signature is REQUIRED upon delivery (price included).Shipping Address for MOC Manual* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Total $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 W. 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 Written cancellation requests received on or before Oct. 23, 2018 will receive a refund, less a $50 processing fee receipt to NWMOA office of the unaltered MOC Handbook. Without return receipt of the unaltered MOC Handbook the cancellation fee will be $200 (includes administrative processing fee and handbook fee). Full payment is required if cancellation is received on or after Oct. 24, 2018 - 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. Final Step of Application ProcessCaptchaPlease enter the letters displayed above to complete your application and then click Submit.