|
Server : Apache/2.4.62 System : FreeBSD fbsdweb2.web.rcn.net 14.1-RELEASE FreeBSD 14.1-RELEASE releng/14.1-n267679-10e31f0946d8 GENERIC amd64 User : www ( 80) PHP Version : 8.3.8 Disable Function : NONE Directory : /domains/thewalshgroup/ |
Upload File : |
<html>
<head>
<meta http-equiv="Content-Type" content="text/html; charset=windows-1252">
<meta http-equiv="Content-Language" content="en-us">
<meta name="GENERATOR" content="Microsoft FrontPage 4.0">
<meta name="ProgId" content="FrontPage.Editor.Document">
<title>Walsh Group</title>
</head>
<body>
<table border="0" cellpadding="0" cellspacing="8" width="801" height="1">
<tr>
<td width="12" height="1" rowspan="2"></td>
<td valign="middle" width="335" nowrap height="1">
<p align="center"><font size="6">Symposium Registration Form</font>
</td>
<td valign="middle" width="370" height="1" rowspan="2">
<p align="center"><font size="3"><b>2-Day International Symposium</b></font></p>
<p align="center"><font color="#FF0000" size="4">Developing Global
Strategies for Identifying, Prosecuting, and Treating Drug-Impaired
Drivers</font></p>
<p align="center" style="word-spacing: 0; margin-top: 0; margin-bottom: 0"><b>Grand Hyatt Tampa Bay</b></p>
<p align="center" style="word-spacing: 0; margin-top: 0; margin-bottom: 0"><b>Tampa, Florida</b></p>
<p align="center"><b>February 23 - 24, 2004</b></p>
</td>
<td width="33" height="1" rowspan="2"></td>
<td width="17" height="1" rowspan="2"></td>
</tr>
<tr>
<td valign="middle" width="335" nowrap height="1" bgcolor="#FFCC99">
<p align="center" style="word-spacing: 0; margin-top: 0; margin-bottom: 0"><b><u><a href="TampaRegistrationOptions.htm">Click
Here</a></u> for hotel information</b></p>
</td>
</tr>
</table>
<p align="left" style="word-spacing: 0; margin-top: 0; margin-bottom: 0">
<b><a href="Tampa.htm"><font face="MS Sans Serif" size="2">Back</font></a></b>
</p>
<p style="word-spacing: 0; margin-top: 0; margin-bottom: 0" align="center"> </p>
<hr>
<!--webbot BOT="GeneratedScript" PREVIEW=" " startspan --><script Language="JavaScript" Type="text/javascript"><!--
function FrontPage_Form1_Validator(theForm)
{
if (theForm.LastName.value == "")
{
alert("Please enter a value for the \"LastName\" field.");
theForm.LastName.focus();
return (false);
}
if (theForm.LastName.value.length > 256)
{
alert("Please enter at most 256 characters in the \"LastName\" field.");
theForm.LastName.focus();
return (false);
}
if (theForm.FirstName.value == "")
{
alert("Please enter a value for the \"FirstName\" field.");
theForm.FirstName.focus();
return (false);
}
if (theForm.FirstName.value.length > 256)
{
alert("Please enter at most 256 characters in the \"FirstName\" field.");
theForm.FirstName.focus();
return (false);
}
if (theForm.Address1.value == "")
{
alert("Please enter a value for the \"Address1\" field.");
theForm.Address1.focus();
return (false);
}
if (theForm.Address1.value.length > 256)
{
alert("Please enter at most 256 characters in the \"Address1\" field.");
theForm.Address1.focus();
return (false);
}
if (theForm.CityStateZip.value == "")
{
alert("Please enter a value for the \"CityStateZip\" field.");
theForm.CityStateZip.focus();
return (false);
}
if (theForm.CityStateZip.value.length > 256)
{
alert("Please enter at most 256 characters in the \"CityStateZip\" field.");
theForm.CityStateZip.focus();
return (false);
}
if (theForm.Country.value == "")
{
alert("Please enter a value for the \"Country\" field.");
theForm.Country.focus();
return (false);
}
if (theForm.Country.value.length > 256)
{
alert("Please enter at most 256 characters in the \"Country\" field.");
theForm.Country.focus();
return (false);
}
if (theForm.PhoneWork.value == "")
{
alert("Please enter a value for the \"PhoneWork\" field.");
theForm.PhoneWork.focus();
return (false);
}
if (theForm.PhoneWork.value.length > 256)
{
alert("Please enter at most 256 characters in the \"PhoneWork\" field.");
theForm.PhoneWork.focus();
return (false);
}
return (true);
}
//--></script><!--webbot BOT="GeneratedScript" endspan --><form action="_vti_bin/shtml.dll/TampaRegistration.htm" method="POST" onsubmit="return FrontPage_Form1_Validator(this)" name="FrontPage_Form1" webbot-action="--WEBBOT-SELF--" language="JavaScript">
<!--webbot bot="SaveResults" startspan U-File="CD_Orders.htm"
S-Format="TEXT/TSV" S-Label-Fields="TRUE" B-Reverse-Chronology="FALSE"
S-Email-Format="TEXT/PRE" B-Email-Label-Fields="TRUE"
B-Email-Subject-From-Field="FALSE" S-Email-Subject="Password Request"
S-Builtin-Fields="REMOTE_NAME REMOTE_USER HTTP_USER_AGENT"
S-Email-Address="[email protected]" --><input TYPE="hidden" NAME="VTI-GROUP" VALUE="0"><!--webbot
bot="SaveResults" endspan i-checksum="43374" -->
<dl>
<dd>
<table width="479">
<tr>
<td width="213">Last Name
<td width="255"><!--webbot bot="Validation" B-Value-Required="TRUE"
I-Maximum-Length="256" --><input type="text" size="50" maxlength="256" name="LastName">
</tr>
<tr>
<td width="213">First Name, Middle Initial
<td width="255"><!--webbot bot="Validation" B-Value-Required="TRUE"
I-Maximum-Length="256" --><input type="text" size="50" maxlength="256" name="FirstName">
</tr>
<tr>
<td width="213">Title (Prof/Dr/Mr/Mrs/Miss/Ms)
<td width="255"><input type="text" size="50" name="Title">
</tr>
<tr>
<td width="213">Mailing Address
<td width="255"><!--webbot bot="Validation" B-Value-Required="TRUE"
I-Maximum-Length="256" --><input type="text" size="50" maxlength="256" name="Address1">
</tr>
<tr>
<td width="213">Mailing Address (continued)
<td width="255"><input type="text" size="50" name="Address2">
</tr>
<tr>
<td width="213">City, State, Zip/Postcode
<td width="255"><!--webbot bot="Validation" B-Value-Required="TRUE"
I-Maximum-Length="256" --><input type="text" size="50" maxlength="256" name="CityStateZip">
</tr>
<tr>
<td width="213">Country
<td width="255"><!--webbot bot="Validation" B-Value-Required="TRUE"
I-Maximum-Length="256" --><input type="text" size="50" maxlength="256" name="Country">
</tr>
</table>
</dd>
<dd>
<table width="479">
<tr>
<td width="212">Telephone Number - Work
<td width="255"><!--webbot bot="Validation" B-Value-Required="TRUE"
I-Maximum-Length="256" --><input type="text" size="35" maxlength="256" name="PhoneWork">
</tr>
<tr>
<td width="212">Telephone Number - Fax
<td width="255"><input type="text" size="35" name="PhoneFax">
</tr>
<tr>
<td width="212">E-mail
<td width="255"><input type="text" size="35" name="Email"> <font color="#FF0000">Confirmation
of your symposium registration will be sent to this e-mail address.</font>
</tr>
<tr>
<td width="212">
<td width="255">
</tr>
<tr>
<td width="212">Preferred First Name (for Badge)
<td width="255"><input type="text" size="35" name="NameOnBadge">
</tr>
<tr>
<td width="212">Institution Name (for Badge)
<td width="255"><input type="text" size="35" name="InstitutionOnBadge">
</tr>
<tr>
<td width="212">
<td width="255">
</tr>
<tr>
<td width="212">
<td width="255">
</tr>
</table>
</dd>
</dl>
<p style="word-spacing: 0; margin-top: 0; margin-bottom: 0"> <strong><font size="4"> Registration
Fees</font></strong><p style="word-spacing: 0; margin-top: 0; margin-bottom: 0"><strong> </strong>
<table border="1" width="50%">
<tr>
<td width="77%" align="center">Before December 31, 2003</td>
<td width="23%" align="center">$125</td>
</tr>
<tr>
<td width="77%" align="center">After December 31,
2003 </td>
<td width="23%" align="center">$150</td>
</tr>
<tr>
<td width="77%" align="center">On-Site</td>
<td width="23%" align="center">$200</td>
</tr>
</table>
<p style="word-spacing: 0; margin-top: 0; margin-bottom: 0"><strong> </strong><p style="word-spacing: 0; margin-top: 0; margin-bottom: 0"> <strong><font size="4"> Method
of Payment</font></strong><p style="word-spacing: 0; margin-top: 0; margin-bottom: 0"> <p style="word-spacing: 0; margin-top: 0; margin-bottom: 0"><strong><font size="3">Preferred
Method:</font></strong>
<dl>
<dd><strong>Charge my: </strong>
<input type="radio" name="Card" value="Visa" checked tabindex="1">Visa
<input type="radio" name="Card" value="MasterCard" tabindex="2">Master
Card </dd>
<table width="371">
<tr>
<td width="102">Card Number
<td width="255"><input type="text" size="35" name="CardNumber">
</tr>
<tr>
<td width="102">Expiration Date
<td width="255"><input type="text" size="35" name="ExpirationDate">
</tr>
<tr>
<td width="102">Name on Card
<td width="255">
<p style="word-spacing: 0; margin-top: 0; margin-bottom: 0"><input type="text" size="35" name="NameOnCard">
</tr>
</table>
</dl>
<table width="575">
<tr>
<td width="110">
<p style="word-spacing: 0; margin-top: 0; margin-bottom: 0">Address
on Card
<td width="451">
<p style="word-spacing: 0; margin-top: 0; margin-bottom: 0"><input type="text" size="35" name="AddressOnCard">
(if different than above)
</tr>
</table>
<table width="573">
<tr>
<td width="110">
<p style="word-spacing: 0; margin-top: 0; margin-bottom: 0">City, State, Zip
<td width="449">
<p style="word-spacing: 0; margin-top: 0; margin-bottom: 0"><input type="text" size="35" name="CityStateZipOnCard">
(if different than above)
</tr>
</table>
<p><b>Alternate Method:</b></p>
<p style="word-spacing: 0; margin-top: 0; margin-bottom: 0">
<input type="radio" name="Card" value="Check will be Mailed" tabindex="3">Check or Money
Order - <i> (Press <b>File</b> then <b>Print</b> to print this
screen)</i>
<p style="word-spacing: 0; margin-top: 0; margin-bottom: 0">
Make check payable to <b>The Walsh Group</b> and mail with printed form to:
<p style="word-spacing: 0; margin-top: 0; margin-bottom: 0">
The Walsh Group
<p style="word-spacing: 0; margin-top: 0; margin-bottom: 0">
6701 Democracy Blvd., Suite 300
<p style="word-spacing: 0; margin-top: 0; margin-bottom: 0">
Bethesda, Maryland 20817
<p style="word-spacing: 0; margin-top: 0; margin-bottom: 0">
Telephone: (301) 571-9494
<p> </p>
<p><a href="mailto:[email protected]"><input type="submit" value="Submit">
</a> <input type="reset" value="Clear Form"></p>
</form>
<hr>
</body>
</html>