Capital Conference Registration 

8:15 a.m. to 2:00 p.m.
 

Name:   Title: 
Company:   
Website:email:
Address:  
City: State, Zip: 
Phone: Dedicated Fax: Cell Phone:

How often do you buy stock under $ 7.00?  Alot Often SeldomNever

How often have you participated in offerings of private of public companies?  Alot OftenSeldomNever

Referred By:

Membership Renewal: (Renew membership and receive free entrance to SCIA's Next conference) $150.00

Registration Entrance Fees: (Fee applies with or without Luncheon.  
This fee is not related to the much higher cost of the banquet food alone.)
$20.00 Member:  (or $30.00 paid at door)

$50.00 Non Member:  (or $60.00 paid at door) 

Luncheon Selection: please select one  
Chicken   Fish   Cannot stay for lunch

I may present the following company (s) at the next conference:

No Charge: I am a current securities licensed broker.  CRD #

CONFERENCE PAYMENT METHOD (Due with Registration): AMEX , VISA, MC, Bank Debit Card       
Card # Exp. /   Card Type Elect. Sign:3 Digits on Card Back (even on AMEX)  Cardholder:  

Credit Card Billing Zip code:  Credit Card Billing Street Address #:

All payments Final – Management Reserves the Right to Refuse Entry

As a Courtesy to Presenters Please Arrive Early