ONLINE REGISTRATION FORM - National Association of State Land Reclamationists ONLINE REGISTRATION FORM ONLINE REGISTRATION FORM ONLINE REGISTRATION FORM

First Name

Last Name

Name Tag ( if different)

Title

State/Organization/Dept

Street Address

City

State/Province

ZIP / Postal Code

Phone

Email Address

Please Select Conference Option *$30 NASLR Virtual Attendance Registration$275 NASLR Conference Registration (incl. Field Trip and Banquet)

$125 Spouuse/Partner/Guest

Registration name for Spouse/Partner/Guest:

Indicate Food Allergy or Preference

VegetarianVeganGluten FreeOther (enter in Special Requests below)

Special Requests

Check if you are also presenting at the conferenceCheck if you are planning to attend the business meetingCheck to receive a certificate for professional development hours

Field Trip Information *I will Participate in the Underground Mine TourI will NOT Participate in the Underground Mine Tour, but will attend the rest of the field tripI will NOT Participate in the Field TripPart of the field trip on October 9th, will be to tour the underground operations of an active coal mine – you must indicate if you wish to participate, and you must provide the following Safety Items for yourself – Hard Hat (that accepts a Head Lamp) and Steel-Toed Boots (Optional Items: Miner’s Belt; Reflective Safety Vest/Shirt; Safety Glasses and Hearing Protection).

Travel Information *I will be drivingI will fly in and drive to Walker's Bluff myselfI will fly into XYZ airport and plan on taking the NASLR shuttle

Total

Credit / Debit Card *

Credit card processing fee

Total Charge

Notes

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