AMTA Racine, WI Workshop Registration – May 2024 Beyond the Surface: Exploring Membrane Water Treatment and Solving PFASHotel Verdant | Racine, WIMay 8-9, 2024 RegistrantSalutation*Mr.Mrs.Ms.Dr.First Name*Middle InitialLast Name*Job Title*Company*Address*City*State*Not Applicable, InternationalAKAZARCACOCTDCDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYZip*Country*AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUSAUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwePhone*CellEmail*Enter registered attendee’s email address WebsiteContact Information Opt. Out Opt. Out * Please check box above if you do not want your contact information shared with event sponsors and exhibitors. Special Needs Food Allergies (describe below) Gluten Free Meals Vegan Meals Vegetarian Meals Wheelchair Access Other (describe below) Special Needs Comments This field is hidden when viewing the formMember AMTA (check all that apply) Billing Contact InformationEnter billing contact information, if applicableBilling Contact NameEnter billing contact’s first and last name, if applicableBilling Contact EmailEnter billing contact’s email address, if applicable Billing Contact Phone Please send copy of the invoice/receipt to Billing Contact Staying at Host HotelMake hotel arrangements through the hotel link on the website or by calling Hotel Verdant by phone at 262-456-6851 and refer to AMTA for room block discount.Will you be staying at the Host Hotel?* Staying at the host hotel Not staying at the host hotel How many nights will you be staying at the Host Hotel?* This field is hidden when viewing the formWorkshop RegistrationDiscount rates apply to registrations that are paid in full by April 19, 2024. To Sponsor/Exhibit click option below. To register as an Attendee, click No Sponsorship and No Exhibit and select appropriate Registration option under Workshop Attendee Discount Rates.Workshop RegistrationTo Sponsor/Exhibit click option below. To register as an Attendee, click No Sponsorship and No Exhibit and select appropriate Registration option under Workshop Attendee.Today – Date MM slash DD slash YYYY Event Sponsor Details Show Sponsorship Details Refreshment Break: $ 600 – Company Name in Brochure and AMTA Promotional Presentation during Breaks – Recognition as a Break Sponsor Breakfast: $ 800 – Company Name in Brochure and AMTA Promotional Presentation during Breaks – Recognition as a Breakfast Sponsor Lunch Lunch Sponsor: $1,650 – Tabletop Exhibit Package – Company Name in Brochure and AMTA Promotional Presentation during Breaks – Recognition as a Lunch Sponsor Major Major Sponsor Package: $1,850 – includes a Tabletop Exhibit Package – Company Logo in Brochure and AMTA Website – Dedicated Slide in the AMTA Promotional Presentation during Breaks – Recognition as a Major Sponsor Facility Tour: $1,000 – $2,000 includes one registration – Company Name in Brochure and AMTA Promotional Presentation during Breaks – Recognition as an Facility Tour Sponsor Networking Event: $2,000 – $ 6,000 – includes one registration – Company Name in Brochure and AMTA Promotional Presentation during Breaks – Recognition as a Networking Event SponsorEvent Sponsor* Refreshment Break Sponsor, $750 Breakfast Sponsor, $875 Lunch Sponsor, $1,850 Major Workshop Sponsor, $2,500 Facility Tour Sponsor, ($1,000-$2,000), $0 Networking Event Sponsor ($2,000-$6,000), $0 No Sponsorship Major Workshop, Lunch, Networking Event and Facility Tour Sponsorships includes one full attendee registration. The Major Workshop Sponsorship includes a Table Top Package. Spaces are selected onsite – first come, first served. Must be a Division 1 (Utility/Government) or Division 2 (Corporate) member to sponsor and exhibit.Networking Event Sponsor ($2,000-$6,000)* Package includes one full attendee registration per $2,000Facility Tour Sponsor ($1,000-$2,000)* Package includes one full attendee registration.Exhibit Space* Table Top Exhibit, $850 No Exhibit One full attendee registration included in Exhibitor Package.Spaces are selected onsite – first come, first served.Must be a Div 1 (Utility) or Div 2 (Corporate) member to exhibit. Select the provided links for more information on types of AMTA Membership.Exhibit Space (included with sponsorship package) Table Top Exhibit One full attendee registration included in Exhibitor Package.Company Description*100-word company descriptionUpload Company Logoplease provide a High Resolution, 300 DPI or greater Drop files here or Select files Accepted file types: jpg, gif, png, pdf, eps, psd, Max. file size: 100 MB. Included Attendee?* I will be the Attendee Send a Registration Link, another person will be attending Speaker/Moderator? Speaker Moderator This field is hidden when viewing the formWorkshop Attendee Discount Rates* AMTA Member, $300 AMTA Utility Member, $175 Non-Member – Operator, $200 Non-Member – All Other Professions, $400 Professor, $75 Govt. Regulators/Full-Time Students, $75 Non-Attendee – Purchase Materials Only, $30 This field is hidden when viewing the formSpeaker/Moderator Workshop Attendee Discount Rates* AMTA Member, $150 AMTA Utility Member, $87.50 Non-Member – Operator, $100 Non-Member – All Other Professions, $200 Professor, $37.50 Govt. Regulators/Full-Time Students, $37.50 Workshop Attendee* AMTA Member, $400 AMTA Utility Member, $275 Non-Member – Operator, $300 Non-Member – All Other Professions, $500 Professor, $100 Govt. Regulators/Full-Time Students, $100 Non-Attendee – Purchase Materials Only, $30 Speaker/Moderator Workshop Attendee* AMTA Member, $200 AMTA Utility Member, $137.50 Non-Member – Operator, $150 Non-Member – All Other Professions, $250 Professor, $50 Govt. Regulators/Full-Time Students, $50 Student ID RequiredMax. file size: 100 MB.Upload Student ID Workshop ActivitiesThis field is hidden when viewing the formOptional Facility Tour*Tues., Oct. 25th – 6:00-8:00pm Attending Optional Facility Tour Not Attending Optional Facility Tour This field is hidden when viewing the formWill you be taking the provided bus to the Optional Facility Tour? Yes No Facility Tour*Wednesday, May 8 – 1:30-4:00 pm Attending Facility Tour Not Attending Facility Tour Will you be taking the provided bus to the Facility Tour? Yes No Networking Event*Wednesday, May 8 – 5:00-7:00 pm Attending Networking Event Not Attending Networking Event This field is hidden when viewing the formWill you be taking the provided bus to the Networking Event? Yes No Guest/Spouse Networking Event*Wednesday, May 8 – 5:00-7:00 pm Guest Attending Networking Event, $25 Guest Not Attending Networking Fun Event Guest Name*Enter Guest’s First and Last NameNeed Contact Hours Certification?* Yes, need contact hours certification No contact hours required Included with registration fee.License #*License State*License Type*License Class* Total FeeTotal $0.00 Payment InformationPayment Method* Credit Card – Online Payment eCheck (Bank Wire w/o processing fee) – Online Payment Invoice Check Mail check made payable to: American Membrane Technology Association 1811 Englewood Rd., #280, Englewood, FL 34223 Comments/QuestionsComments Cancellations and RefundsWritten cancellation requests received by AMTA on or before Friday, April 19, 2024 will receive a refund, less a $50 processing fee. No refunds and no credits for future events will be granted if requested after Friday, April 19, 2024 (unless AMTA cancels the event). However, substitutions may be made at any time. AMTA reserves the right to make changes in programs and speakers, or to cancel programs when conditions beyond its control prevail. Every If a program is not held, AMTA’s liability is limited to the refund of the program fee only. Final Step of Application ProcessPlease enter the letters displayed below to complete your application and then click Submit.CAPTCHAPlease refer to AMTA’s Privacy Policy if you have any questions regarding your preferences.