Attendee Registration Form Mountain States Ground Water Expo | February 8, 2019 - February 9, 2019 Aquarius Casino Resort Laughlin, NevadaKeep this field blank: First name*: Last Name*: Required field Company: Address: City: State: Zip: Telephone: Fax: E-Mail*: Required field Members: Mark all that apply Arizona Water Well Association: Colorado Water Well Contractors Assoc.: New Mexico Ground Water Association: Utah Ground Water Association: Nevada Ground Water Association: Other: Tickets Registration Fee includes Thursday and Friday morning continental breakfasts, Friday lunch,Thursday evening Exhibitor’s Reception, admission to all seminars and Exhibit Hall: 12345 Contractor - $80 ($100 after January 31, 2019 and onsite) 12345 Spouse/Employee [List Name(s) Below] - $65 ($85 after January 31, 2019 and onsite) 12345 Thursday evening ONLY guest pass $30 ($40 after January 31, 2019 and onsite) 12345 Friday Lunch only $15 12345 Student $50 ($70 after January 31, 2019 and onsite) 12345 Scholarship Recipient No charge 12345 Technical $80 ($100 after January 31, 2019 and onsite) 12345 Non-Exhibiting Manufacturer/Supplier $140 ($180 after January 31, 2019 and onsite) Spouse/Employee/Other(s) First and Last name of Spouse/Employee/Other(s): First Name: Last Name: First Name: Last Name: First Name: Last Name: First Name: Last Name: I/We will donate 12345678910 item(s) to the Buck Lively Scholarship Auction and Raffle I/We would like to donate $ to the Buck Lively Scholarship Fund. NOTE: All companies and individuals making donations will be acknowledged as their items are auctioned or raffled off unless requested otherwise. All income generated for the Buck Lively Scholarship Fund is evenly distributed among the scholarship programs of the 5 state associations hosting the Expo. CANCELLATION POLICY: 50% if notified by January 31, 2019; No refunds after that date.