World ATM Congress 2017

CONTACT INFORMATION

Provide the following contact information • Items noted with an asterisk (*) are required • Click Continue to proceed

Personal Information
Category:	Delegate
* Forename:	* required *
* Surname/Family Name:	* required *
Informal Name/Nickname (for badge):
Title/Position/Rank:
Duplicate Email Address The email address entered has already been used on another registration. Please enter the registrant's email address to continue.
You must provide each registered attendee's email address. Use of the same registrant email address on more than one registration will NOT be allowed.
* Registrant's E-Mail Address:	* required
* Confirm E-Mail Address:	* required
Create a password to be used to login and view/edit your registration
* Create a Password:	* required
* Confirm the Password:	* required
Group Registration: (Details)	YesNo (Registering more than one person for this Event) Answering Yes to this question will allow you to register more than one person on the same registration. If there are fees involved with this event, the fees for all registrants in the group will be added together and charged to the first person in the group. If different members of the group are paying individually (for example with different credit cards), you must answer No to this question and create separate registrations for each.
Contact/Administrative E-Mail Address (optional):
	Registrant agrees to receive World ATM Congress emails at the email addresses entered above
	Will be used for email confirmations (the email address of the person completing this form if not the registrant) For group registrations, a group summary email will be sent to this email address
Company Information
* Company/Organization:	* required *
* Company Name for Badge:	* required *
* Business Address:	* required *
Business Address Line 2:
P.O. Box/Mail Stop:
* Country:	* required
* Zip/Postal Code:	* required *
* City:	* required *
* U.S. State:	* required
* Phone:	* required * *
Fax:	* *
Mobile Phone:	* *
	I consent to receive World ATM Congress text messages
* City:	* required *
* Canadian Province:	* required
Intl State/County/Province:
Zip/Postal Code:	*
	Country Code + Number
* Phone:	* * + * required * *
Fax:	* * + *
Mobile Phone:	* * + * *
	I consent to receive World ATM Congress text messages
Additional Information
Emergency Contact:	Full Name
Emergency Contact Phone Number:	include Country Code
Special Needs/Assistance: please provide a brief description

* Please add worldatmcongress@completereg.com to your safe sender list to prevent email confirmations from going to your spam folder

Verify the information below and click on Add Attendee to Waitlist. Click Close to exit this screen.
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Forename:
Surname/Family Name:
Phone:
E-Mail Address:
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CONTACT INFORMATION

Personal Information

Company Information

Additional Information