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DATIA 2018 Annual Conference Registration Form

* required
Company Name* Registrant Name*
Address* City* State* Zip*
Phone* Fax Email*
Please indicate which industry segment you represent with the following options:

Employer
Product Manufacturer/Provider
Collection Facility
Consortium/TPA
Medical Review Officer (MRO)
Substance Abuse Professional (SAP)
Employee Assistance Programs (EAP)
Other

If Other, please specify
Please indicate any special dietary needs (food allergies, vegan, vegetarian, etc.)
  Normal Rate Registrant Name Registrant Email
Members $549
Members - 2nd person $499
Members - 3rd person $449
Members - 4th person $399
Members - 5th person $349
Non-Members $699
Non-Members - 2nd person $649
Non-Members - 3rd person $599
Non-Members - 4th person $549
Non-Members - 5th person $499




*Please note that if you register more than 5 people, additional people will be registered at the 5th person rate.
SAVE BIG!!! Sign up as a DATIA member now and save $100 on each conference and training course registration. Memberships are company memberships so YOU WILL SAVE MORE than the dues fee if you sign up for more than one item or sign up more than one person.
(Visit datia.org for complete membership benefit breakdowns)
$148 Regular Member (1-5 employees) $298 Corporate Member (6+ employees) $1150 Sustaining Member
DATIA Opening Reception
(Included in registration fee for registrants. NOTE: Guests accompanying attendees must register to attend.)
$30 x # Guest name(s):
Wednesday Evening Networking Event
(Included in registration fee for registrants. NOTE: Guests accompanying attendees must register to attend.)
$50 x # Guest name(s):
Training Courses
Auditing Success
Participant_1: Tuesday, May 22, 2018
Friday, May 25, 2018
$279 Member
$379 Non-member
Participant Name
Collector Refresher and Mock Collection Course
Participant_1: Tuesday, May 22, 2018 $279 Member
$379 Non-member
Participant Name
Ins and Outs of Drug and Alcohol Testing
Participant_1: Tuesday, May 22, 2018 $279 Member
$379 Non-member
Participant Name
Developing an Effective Supervisor Training Program
Participant_1: Tuesday, May 22, 2018
Friday, May 25, 2018
$279 Member
$379 Non-member
Participant Name
Excelling as an MRO Assistant Workshop
Participant_1: Tuesday, May 22, 2018 $379 Member
$479 Non-member
Participant Name
Certified Professional Collector Trainer® Training
Participant_1: Tuesday, May 22, 2018
Friday, May 25, 2018
$379 Member
$479 Non-member
Participant Name
Consortia/Third Party Administrator Best Practices
Participant_1: Tuesday, May 22, 2018
Friday, May 25, 2018
$379 Member
$479 Non-member
Participant Name
DER Compliance: A Train-the-Trainer Workshop
Participant_1: Tuesday, May 22, 2018
Friday, May 25, 2018
$379 Member
$479 Non-member
Participant Name
Advanced DER Training
Participant_1: Friday, May 25, 2018 $279 Member
$379 Non-member
Participant Name
Advanced Collection Issues and Best Practices
Participant_1: Friday, May 25, 2018 $279 Member
$379 Non-member
Participant Name

Payment Information
Total Due:$
Option 1: Pay By Check

To pay by check, please print this form and mail it to:

DATIA 1325 G Street NW
Suite 500 #5001
Washington, DC 20005

The total amount due on this form will be honored.

Registration is not complete until payment is received.


Option 2: Pay By Credit Card

Credit Card Type: MasterCard
Visa
American Express
Card #:
Expiration Date:


Type the code shown in parentheses (DATIA2018):

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