Educational Retreat & Conference Registration Form
Please identify which type of transaction you are using the form for at this time:
Type of Submission
Original Conference Registration Updated Registration Information Other
Date this application is being filed (e.g., January 1, 1998)
Date & Place of Conference
Hannaian Winter 2006 Investment Retreat - Stuart, Florida
Full name of person submitting this Registration (e.g John A. Smith)
Registrant's First Name:
Registrant' Last Name:
Middle Initial:
Email Address:
Internet Website Address
Street Address:
City:
State:
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delawa re Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan<Opti on Value=Minnesota>Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming
Zip Code:
Country:
Country Mailing Code:
Home Telephone #:
( )
Business Telephone #:
Fax Number:
Gender:
Male Female
Age:
Regular Occupation:
Referring Publisher's Name & I.E.P. Code if appilcable:
How did you hear about our Educational Retreat & Conference
How would you describe your experience as a private business person
Highly Experienced Moderate Experience Some Experience No Experience
Do you now, or have you ever worked in the Securities Industry
Yes No
.......If yes briefly describe your prior or present activity in the Securities Industry
How would you describe your investing or trading experience in the Public Securities Markets
How would you describe your investing or trading experience in the Private Securities Markets
Are you currently, or in the past, been involved with the Entertainment, Literary, or Software development industries:
.......If yes, briefly describe your prior or present activity in the Entertainment Literary, or Software development industries:
Type of Conference Registration Fees
Non-HIPG Winter 2006 Registrant - Open Sessions & Luncheon...$39... Non-HIPG Registrant Applying for Affiliation, All Sessions & Luncheon, Winter 2001 Conference .... $225...After Dec. 1, $235 HIPG Publisher Affiliate Winter Retreat 2006 Luncheon TicketAfter Dec. 1, $30 Non-HBN Bloomfield Affiliate Registration Friday $25 Non HBN Bloomfield Affiliate Saturady Registration $35 Non-HBN Bloomfield Registration Both Days $50 HBN-Bloomfield Affiliate Registration $25 HIPG Affiliate - Cooper-Jones Education & Economic Summit General Registration - Cooper-Jones Education & Economic Summit
You may pay by credit card, check or money order. Please Select Payment Method:
Credit Card Check Money Order
If paying by credit card fill in the following, or if you prefer, alternatively fax or phone in your credit card information.
CC. Type:
VISA Master Card Discover
Credit Card Number:
Expiration Date:
Remember you must make your hotel reservations directly with the hotel or the travel agent. Please do so as soon as possible to ensure you receive the special room rates.