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Conference Registration

Please note:

  • Please complete and return this form with your Registration Fee by April 21, 2017

  • Fields marked with an asterisk (*) are required.


Billing Information
* Payor First Name field is required.
* Payor Last Name field is required.

* Billing Address 1 field is required.
*

* City field is required.
*
* Payor Administrative Division field is required.
*
Zip Code is required. Field must be in zip code format(12345 or 12345-6789).
Zip Code is required. Zip Code field must be 6 digits.

* Payor Phone Number field is required.
* Payor Email Address is required. Invalid Email

Participant Information
    Same as Billing?
* Name field is required.
* Title/Position field is required.
* Type field is required.

* School/Institution/Business/Other Name field is required.
* Mailing Address field is required.
* City field is required.

* State field is required.
* Zip Code is required. Field must be in zip code format(12345 or 12345-6789)
* Email Address is required. Invalid Email

* Business Phone Number field is required.
* Cell Phone Number field is required.

  •    
Vegetarian Option field is required.
  •    
Registration Fees Enclosed field is required.

   
Applying As field is required.

  • Registration Fee for general participants & presenters ($75), and students ($40) includes all conference materials, breakfast, luncheon and refreshments.

  • Attendee is responsible for other MEBCEA related expenses including travel, lodging, and meals other than the luncheon.


(Please make check or money order payable to the UAPB School of Education - Educational Access)


(Please include each participant’s name on Purchase Order)


    
Continuing Education field is required.

Please return the above form with your Registration Fee to:

School of Education

Educational Access Registration Committee

1200 North University Drive, Mail Slot 4927

Pine Bluff, Arkansas 71601

Telephone (870) 575-7008 or 8989 ● Fax (870) 575-8484


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