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<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"> <html> <head> <TITLE>Conference Registration Page</TITLE> <meta name="vs_defaultClientScript" content="JavaScript"> <meta name="vs_targetSchema" content="http://schemas.microsoft.com/intellisense/ie5"> <meta name="GENERATOR" content="Microsoft Visual Studio .NET 7.1"> <meta name="ProgId" content="VisualStudio.HTML"> <meta name="Originator" content="Microsoft Visual Studio .NET 7.1"> <META NAME="GENERATOR" CONTENT="Microsoft FrontPage 4.0"> <META HTTP-EQUIV="content-type" CONTENT="text/html;charset=iso-8859-1"> </head> <BODY BGCOLOR="#ffffff" LINK="#000066" ALINK="#000066" style="FONT-SIZE: 9pt; FONT-FAMILY: Arial, Helvetica"> <FORM METHOD="get" ACTION="PMAMailForm.aspx" ENCTYPE="x-www-form-urlencoded" ID="Form1"> <TABLE CELLPADDING="1" CELLSPACING="5" BORDER="3" bordercolor="#000066" WIDTH="600" ID="Table1" bgcolor="#eeeeff" align="center"> <tbody> <TR> <TD COLSPAN="3"> <p align="center"><STRONG><FONT COLOR="#000066" SIZE="+2"><br>Conference Registration</FONT></STRONG></p> <p align="center"><FONT COLOR="#000066" SIZE="-1">Please complete and submit this form to register for a conference.</FONT></p> <p align="center"><FONT COLOR="#000066" SIZE="-1"><em>Questions? Prefer to register by phone?<br> Call PMA Conference Management at 201 871 0474</em></FONT></p> <INPUT TYPE="hidden" NAME="to" VALUE="[email protected]" ID="Hidden1"> <INPUT TYPE="hidden" NAME="from" VALUE="[email protected]" ID="Hidden2"> <INPUT TYPE="hidden" NAME="subject" VALUE="generic registration form" ID="Hidden3"> <CENTER> <TABLE BORDER="0" CELLSPACING="2" CELLPADDING="0" WIDTH="447" ID="Table2"> <tbody> <TR> <TD ALIGN="right" WIDTH="126"> <EM>Name</EM></TD> <TD WIDTH="15"></TD> <TD WIDTH="297"> <INPUT NAME="Name" SIZE="35" TYPE="text" ID="Text1"> </TD> </TR> <TR> <TD ALIGN="right" WIDTH="126"> <EM>Title</EM></TD> <TD WIDTH="15"></TD> <TD WIDTH="297"> <INPUT NAME="Title" SIZE="35" TYPE="text" ID="Text2"> </TD> </TR> <TR> <TD ALIGN="right" WIDTH="126"> <EM>Organization</EM></TD> <TD WIDTH="15"></TD> <TD WIDTH="297"> <INPUT NAME="Organization" SIZE="35" TYPE="text" ID="Text3"> </TD> </TR> <TR> <TD ALIGN="right" WIDTH="126"> <EM>Street address</EM></TD> <TD WIDTH="15"></TD> <TD WIDTH="297"> <INPUT NAME="StreetAddress" SIZE="35" TYPE="text" ID="Text4"> </TD> </TR> <TR> <TD ALIGN="right" WIDTH="126"> <EM>Address (cont.)</EM></TD> <TD WIDTH="15"></TD> <TD WIDTH="297"> <INPUT NAME="Address2" SIZE="35" TYPE="text" ID="Text5"> </TD> </TR> <TR> <TD ALIGN="right" WIDTH="126"> <EM>City</EM></TD> <TD WIDTH="15"></TD> <TD WIDTH="297"> <INPUT NAME="City" SIZE="35" TYPE="text" ID="Text6"> </TD> </TR> <TR> <TD ALIGN="right" WIDTH="126"> <EM>State/Province</EM></TD> <TD WIDTH="15"></TD> <TD WIDTH="297"> <INPUT NAME="State_provence" SIZE="35" TYPE="text" ID="Text7"> </TD> </TR> <TR> <TD ALIGN="right" WIDTH="126"> <EM>Zip/Postal code</EM></TD> <TD WIDTH="15"></TD> <TD WIDTH="297"> <INPUT MAXLENGTH="12" NAME="ZipCode" SIZE="12" TYPE="text" ID="Text8"> </TD> </TR> <TR> <TD ALIGN="right" WIDTH="126"> <EM>Country</EM></TD> <TD WIDTH="15"></TD> <TD WIDTH="297"> <INPUT NAME="Country" SIZE="25" TYPE="text" ID="Text9"> </TD> </TR> <TR> <TD ALIGN="right" WIDTH="126"> <EM>Work Phone</EM></TD> <TD WIDTH="15"></TD> <TD WIDTH="297"> <INPUT MAXLENGTH="25" NAME="WorkPhone" SIZE="25" TYPE="text" ID="Text10"> </TD> </TR> <TR> <TD ALIGN="right" WIDTH="126"> <EM>FAX</EM></TD> <TD WIDTH="15"></TD> <TD WIDTH="297"> <INPUT MAXLENGTH="25" NAME="FAX" SIZE="25" TYPE="text" ID="Text11"> </TD> </TR> <TR> <TD ALIGN="right" WIDTH="126"> <EM>E-mail</EM></TD> <TD WIDTH="15"></TD> <TD WIDTH="297"> <INPUT NAME="Email" SIZE="25" TYPE="text" ID="Text12"> </TD> </TR> </tbody> <TR> <TD WIDTH="126"></TD> <TD WIDTH="15"></TD> <TD WIDTH="297"></TD> </TR> <TR> <TD WIDTH="126"> </TD> <TD WIDTH="15"> </TD> <TD WIDTH="297"> </TD> </TR> <TR> <TD WIDTH="126"> <P ALIGN="right"><I>Event</I></P> </TD> <TD WIDTH="15"></TD> <TD WIDTH="297"> <INPUT TYPE="text" NAME="textfieldName" SIZE="40" ID="Text13"> </TD> </TR> <TR> <TD WIDTH="126" VALIGN="bottom"> <P ALIGN="right"><I>Pre/post Conference Seminar(s)</I></P> </TD> <TD WIDTH="15"> </TD> <TD WIDTH="297"> <TEXTAREA NAME="seminars" ROWS="3" COLS="36" ID="Textarea1"></TEXTAREA></TD> </TR> <TR> <TD WIDTH="126"> <P ALIGN="right"><I>Event Date</I></P> </TD> <TD WIDTH="15"></TD> <TD WIDTH="297"> <INPUT TYPE="text" NAME="textfieldName" SIZE="24" ID="Text14"> </TD> </TR> <TR> <TD WIDTH="126"> <P ALIGN="right"><I>Event Location</I></P> </TD> <TD WIDTH="15"></TD> <TD WIDTH="297"> <INPUT TYPE="text" NAME="textfieldName" SIZE="24" ID="Text15"> </TD> </TR> <TR> <TD WIDTH="126"> </TD> <TD WIDTH="15"> </TD> <TD WIDTH="297"> </TD> </TR> <TR> <TD WIDTH="126"> <P ALIGN="right"><I>Total Charge</I></P> </TD> <TD WIDTH="15"> </TD> <TD WIDTH="297"> $<INPUT NAME="total_charge" TYPE="text" SIZE="15" ID="Text16"></TD> </TR> </TABLE> </CENTER> <P/><CENTER><HR WIDTH="70%" SIZE="3" NOSHADE> </CENTER> <P/><CENTER> <TABLE BORDER="0" WIDTH="443" CELLSPACING="2" CELLPADDING="0" ID="Table3"> <tbody> <TR> <TD colspan="2" align="center"> <font color="#000066" size="+1"><STRONG>Billing<br><br></STRONG></font></TD> </TR> <TR> <TD> <P ALIGN="right"><EM>Credit card</EM></P> </TD> <TD> <SELECT NAME="Ordering_CardType" ID="Select1"> <OPTION VALUE="VISA " SELECTED> VISA <OPTION VALUE="MasterCard "> MasterCard <OPTION VALUE="American Express"> American Express</OPTION> </SELECT></TD> </TR> <TR> <TD ALIGN="right"> <EM>Cardholder name</EM></TD> <TD> <INPUT NAME="Ordering_CardHolderName" SIZE="35" TYPE="text" ID="Text17"> </TD> </TR> <TR> <TD ALIGN="right"> <EM>Card number</EM></TD> <TD> <INPUT NAME="Ordering_CardNumber" SIZE="20" TYPE="text" ID="Text18"> </TD> </TR> <TR> <TD ALIGN="right"> <EM>Expiration date</EM></TD> <TD> <INPUT MAXLENGTH="5" NAME="Ordering_CardExpiration" SIZE="5" TYPE="text" ID="Text19"> </TD> </TR> <TR> <TD ALIGN="right"></TD> <TD></TD> </TR> <TR> <TD ALIGN="right"> <EM>Bill Me</EM></TD> <TD> <INPUT NAME="Bill_Me" TYPE="checkbox" VALUE="yes" ID="Checkbox1"><FONT SIZE="-1">Send invoice to the address provided above</FONT></TD> </TR> </tbody> </TABLE> </CENTER> <P/><CENTER><TEXTAREA COLS="57" NAME="Comments" ROWS="6" ID="Textarea2">Use this space to list all the attendees in groups, special instructions, or even to request that we call you. </TEXTAREA></CENTER> <P></P> <P/><CENTER><INPUT TYPE="submit" VALUE="Submit Form" ID="Submit1" NAME="Submit1"> <INPUT TYPE="reset" VALUE="Reset Form" ID="Reset1" NAME="Reset1"></CENTER> <p align="center"><STRONG><FONT COLOR="#000066" size="+1">Thank you for your registration!</FONT></STRONG></p> <p align="center"><FONT COLOR="#000066" size="-1">PMA Conference Management is a division of PMA Publications. PMA publishes</font></p> <table align="center" border="0" cellpadding="0" cellspacing="0"> <tr> <td><font color="#000066" size="-1"> <ul> <li><a href="http://www.powermarketers.com">powermarketers.com</a>, </li> <li><a href="http://www.hrnewswatch.com">hrnewswatch.com</a>, </li> <li><a href="http://www.organicnewstoday.com">organicnewstoday.com</a>, </li> <li><a href="http://www.mortgagenewswatch.com">mortgagenewswatch.com</a> and </li> <li><a href="http://www.eldercarenewstoday.com">eldercarenews.com</a></li> </ul></font> </td> </tr> </table> </TD> </TR> <!-- fINAL ROW TO PIN WIDTH OF SECOND COLUMN --></tbody> </TABLE> </FORM> </BODY> </html>