REGISTRATION FORM
2018 TMPAA Mid-Year Meeting
Where Program Business Gets Done
May 7 - 9 Hilton Baltimore, Baltimore, MD
(
* please answer all questions
)
First Name
(as you want it to appear on your name tag)
Last Name
Agency Name
Agency Address
City
State
--Select One--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington, D.C.
West Virginia
Wisconsin
Wyoming
N/A
Zipcode
Country
United States
Canada
United Kingdom
Telephone
(
)
-
International Telephone (if not U.S.)
Mobile Telephone
For use ONLY on printed attendee list distributed at meeting and mobile app.
(
)
-
E-Mail
Agency Website
Position
Please list up to three programs you currently administer (for Attendee list)
(Limited to 50 characters) -
Please do not omit this information.
Membership Status / Conference Fee:
Members - $995
Non-Members - $1195
Pay Options:
Check (payable to Target Markets)
VISA
MasterCard
AMEX
Meeting Credit (Previously approved by TMPAA)
Credit Card Billing Information (if paying by Credit Card):
Name, Address same as above.
For your protection, our credit card system has implemented a security feature called an “Address Verification System” (AVS). This ensures that when you enter the correct billing address and zip code for your payment, it
MUST MATCH WHAT YOU HAVE ON FILE WITH THE BANK THAT HAS ISSUED YOUR CREDIT CARD
. In other terms, if it does not match, your payment will be declined automatically.
Billing First Name:
Billing Last Name:
Billing Address:
Billing City:
Billing State:
--Select One--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington, D.C.
West Virginia
Wisconsin
Wyoming
N/A
Billing Zip Code:
Billing Country:
United States
Canada
United Kingdom
Billing Phone:
Card Number:
Exp Date:
01
02
03
04
05
06
07
08
09
10
11
12
/
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
CVV2 Number:
What is a CVV2 Code?
Would you care to make a donation to TMPAA Charities?
$50
$100
$250
$500
Other:
Don't forget to book a room at the Hilton Baltimore!