AMTA Workshop Registration – Des Moines, IA AMTA Workshop Registration - May 2022 Planting the Seeds for Membrane in the Midwest USDes Moines, IATuesday-Thursday, May 10-12, 2022 RegistrantSalutation*Mr.Mrs.Ms.Dr.First Name* Middle Initial Last 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* Cell Email*Enter registered attendee's email address Website Contact Information Opt. Out Opt. Out * Please check box above if you do not want your contact information shared with event sponsors. Special Needs Food Allergies (describe below) Gluten Free Meals Vegan Meals Vegetarian Meals Wheelchair Access Other (describe below) Special Needs Comments Member AMTA (check all that apply) Billing Contact InformationEnter billing contact information, if applicableBilling Contact NameEnter billing contact's first and last name, if applicable Billing Contact Email Enter billing contact's email address, if applicableBilling Contact Phone Please send copy of the invoice/receipt to Billing Contact Staying at Host HotelMake hotel arrangements directly with West Des Moines Marriott by phone at (515)267-1500. Refer to AMTA for the discounted room rate. Book by Sunday, April 24, 2022 and save!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?* Workshop RegistrationDiscount rates apply to registrations that are paid in full by April 25th. 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.HiddenWorkshop 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 Silver: $ 800 - Company Name in Brochure and AMTA Promotional Presentation during Breaks - Recognition as a Breakfast Sponsor Gold Gold-A Package: $1,200 - includes one registration Gold-B Package: $1,650 - includes a Table Top Package - Company Name in Brochure and AMTA Promotional Presentation during Breaks - Recognition as a Lunch Sponsor Platinum Platinum-A Package: $1,400 - includes one registration Platinum-B Package: $1,850 - includes a Table Top Package - Company Logo in Brochure and AMTA Website - Dedicated Slide in the AMTA Promotional Presentation during Breaks - Recognition as a Major Sponsor Optional Tour: $1,000 - includes one registration - Company Name in Brochure and AMTA Promotional Presentation during Breaks - Recognition as an Optional Tour Sponsor Networking Event: $1,500 - $ 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, $600 Breakfast Sponsor, $800 Lunch Sponsor, $1,650 Major Workshop Sponsor, $1,850 Networking Event Sponsor ($2,000-$6,000), $0 Facility Tour Sponsor ($1,000-$2,000), $0 No Sponsorship Major Workshop, Lunch, Networking Event and Facility Tour Sponsorships includes one full attendee registration The Major Workshop Sponsor includes a Table Top Package. Spaces are selected onsite - first come, first served. Must be a Div 1 (Utility/Government) or Div 2 (Corporate) member to 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, $750 No Exhibit One full attendee registration included in Exhibitor Package.Spaces are selected onsite - first come, first served.Must be a Div 1 (Utility/Government) 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 HiddenWorkshop Attendee Discount Rates*If not a member, Join AMTA Now for Member Discounted Rates. AMTA Member, $300 AMTA Utility/Government Member, $150 Non-Member - Operator, $175 Non-Member - All Other Professions, $400 Govt. Regulators/Full-Time Students, $75 Non-Attendee - Purchase Materials Only, $30 Non-Attendee Tuesday Networking Reception Only, $25 HiddenSpeaker/Moderator Workshop Attendee Discount Rates*If not a member, Join AMTA Now for Member Discounted Rates. AMTA Member, $150 AMTA Utility/Government Member, $87.50 Non-Member - Operator, $100 Non-Member - All Other Professions, $200 Govt. Regulators/Full-Time Students, $37.50 Workshop Attendee*If not a member, Join AMTA Now for Member Discounted Rates. AMTA Member, $400 AMTA Utility/Government Member, $175 Non-Member - Operator, $200 Non-Member - All Other Professions, $500 Govt. Regulators/Full-Time Students, $100 Non-Attendee - Purchase Materials Only, $30 Speaker/Moderator Workshop Attendee*If not a member, Join AMTA Now for Member Discounted Rates. AMTA Member, $200 AMTA Utility/Government Member, $137.50 Non-Member - Operator, $100 Non-Member - All Other Professions, $250 Govt. Regulators/Full-Time Students, $50 Student ID RequiredMax. file size: 100 MB.Upload Student ID Workshop ActivitiesOptional Networking Event*At Hotel Tues., May 10, 2022 Attending Optional Networking Event Not Attending Optional Networking Event Facility Tour*Grimes Water Treatment Plant Wed., May 11th - 1:30-4:00pm Attending Facility Tour Not Attending Facility Tour Networking Event*Smash Park Wed., May 11th - 5:00-7:00 pm Attending Networking Event Not Attending Networking Event Guest/Spouse Tuesday Networking Event*Tuesday, May 10th - 5:00-7:00 pm Guest Attending Networking Event, $10 Guest Not Attending Networking Fun Event Guest/Spouse Wednesday Networking Event*Wednesday, May 11th - 5:00-7:00 pm Guest Attending Networking Event, $10 Guest Not Attending Networking Fun Event Guest Name*Enter Guest's First and Last Name Need 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 Check Invoice Mail check made payable to: American Membrane Technology Association PO Box 14918, Tallahassee, FL 32317 Comments/QuestionsComments Cancellations and RefundsWritten cancellation requests received by AMTA on or before April 25, 2022 will receive a refund, less a $50 processing fee. Full payment is required if cancellation is received on or after April 25, 2022 - no refunds and no credits for future events will be granted. 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 effort will be made to contact each enrollee if a program is cancelled. 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.