This is the NEW form. For testing only. Conference Registration TEST merchant@cbconference.org How many people are you registering for this event?*Please enter a number from 1 to 6.You may register up to 6 people total using this form. First Name* Last Name* Badge Name* Address type for primary registrant* United States Other Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Non-US address for primary registrantPlease add information for your international address & phone number in the comments field as neededContact Phone*Email* Enter Email Confirm Email Payment Email*IMPORTANT!!! - This is the email address that is either your PayPal email account OR the email account you will use when providing Credit Card payment information on the next page. Registration type for registrant 1 AA Al-Anon AA/Alanon Non-Program Ala-20 (20-29) Alateen (13-19) Preteen (10-12) Tween (7-9) 6 and under Please let us know the age of this registrant.*Please select an age12345678910111213141516171819NOTE: Registering children ages 7-12 indicates your willingness to volunteer for one afternoon children’s program (3:15-5:15PM)Sunday DinnerSelect YES if you will be joining us for dinner Sunday evening. Dinner is $40.00/person No Yes Will you be playing in the Bill Wilson Open Golf Tournament? No Yes HandicapPlease enter a number from 1 to 56.Purchase Mulligans Mulligans 0 Mulligans 1 Mulligans 2 Mulligans 3 Mulligans 4 Mulligans Is this your 1st year at the conference?* Yes No How many years have you been in AA or Al-Anon? Please check the areas that you are willing to provide services for Workshop leader Discussion Leader Activities Information desk Green Shirts Alateen Preteen Tween Please add any additional comments belowRegistrant 1 subtotalRegistrant 2First name registrant 2* Last name registrant 2* Email for registrant 2 Badge Name of registrant 2* Does registrant 2 have a different address than registrant 1? Yes, it is a different address Contact info for Registrant 2Address type for registrant 2* United States Other Address of registrant 2 Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Non-US address registrant 2Please add information for your international address & phone number in the comments field as neededPhone for registrant 2HiddenRegistration type for registrant 2 AA Al-Anon AA/Alanon Non-Program Ala-20 (20-29) Alateen (13-19) Preteen (10-12) Tween (7-9) 6 and under Please let us know the age of registrant 2*Please select an age12345678910111213141516171819Sunday Dinner for registrant 2Select YES if you will be joining us for dinner Sunday evening. Dinner is $40.00/person No Yes Will registrant 2 be playing in the Open Golf Tournament? No yes Handicap for registrant 2Please enter a number from 1 to 56.Purchase mulligans for registrant 2 Mulligans 0 Mulligans 1 Mulligans 2 Mulligans 3 Mulligans 4 Mulligans Is this the first conference for registrant 2?* Yes No Please check the areas that registrant 2 will be willing to provide services for. Workshop leader Discussion Leader Activities Information desk Green Shirts Alateen Preteen Tween How many years has registrant 2 been in AA or Al-Anon? Registrant 2 subtotalRegistrant 3First name of registrant 3* Last name of registrant 3* Email for registrant 3 Badge Name of registrant 3* Does registrant 3 have a different address than Registrant 1? Yes, it is a different address Contact info for Registrant 3Address type for registrant 3* United States Other Address of registrant 3 Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Non-US address registrant 3Please add information for your international address & phone number in the comments field as neededPhone for registrant 3HiddenSection BreakRegistration type for registrant 3 AA Al-Anon AA/Alanon Non-Program Ala-20 (20-29) Alateen (13-19) Preteen (10-12) Tween (7-9) 6 and under Please let us know the age of registrant 3*Plesae select an age12345678910111213141516171819Sunday Dinner for registrant 3Select YES if you will be joining us for dinner Sunday evening. Dinner is $40.00/person No Yes Will registrant 3 be playing in the Open Golf Tournament? No Yes Handicap for registrant 3Please enter a number from 1 to 56.Purchase mulligans for registrant 3 Mulligans 0 Mulligans 1 Mulligans 2 Mulligans 3 Mulligans 4 Mulligans Is this the first conference for registrant 3?* Yes No Please check the areas that registrant 3 will be willing to provide services for. Workshop leader Discussion Leader Activities Information desk Green Shirts Alateen Preteen Tween How many years has registrant 3 been in AA or Al-Anon? Registrant 3 subtotalRegistrant 4First name of registrant 4* Last name of registrant 4* Email for registrant 4 Badge Name of registrant 4* Does registrant 4 have a different address than Registrant 1? Yes, it is a different address Contact info for Registrant 4Address type for registrant 4* United States Other Address of registrant 4 Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Non-US address registrant 4Please add information for your international address & phone number in the comments field as neededPhone for registrant 4HiddenSection BreakRegistration type for registrant 4 AA Al-Anon AA/Alanon Non-Program Ala-20 (20-29) Alateen (13-19) Preteen (10-12) Tween (7-9) 6 and under Please let us know the age of registrant 4*Plesae select an age12345678910111213141516171819Sunday Dinner for registrant 4Select YES if you will be joining us for dinner Sunday evening. Dinner is $40.00/person No Yes Will registrant 4 be playing in the Open Golf Tournament? No Yes Handicap for registrant 4Please enter a number from 1 to 56.Purchase mulligans for registrant 4 Mulligans 0 Mulligans 1 Mulligans 2 Mulligans 3 Mulligans 4 Mulligans Is this the first conference for registrant 4?* Yes No Please check the areas that registrant 4 will be willing to provide services for. Workshop leader Discussion Leader Activities Information desk Green Shirts Alateen Preteen Tween How many years has registrant 4 been in AA or Al-Anon? Registrant 4 subtotalRegistrant 5First name of registrant 5* Last name of registrant 5* Email for registrant 5 Badge Name of registrant 5* Does registrant 5 have a different address than Registrant 1? Yes, it is a different address Contact info for Registrant 5Address type for registrant 5* United States Other Address of registrant 5 Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Non-US address registrant 5Please add information for your international address & phone number in the comments field as neededPhone for registrant 5HiddenSection BreakRegistration type for registrant 5 AA Al-Anon AA/Alanon Non-Program Ala-20 (20-29) Alateen (13-19) Preteen (10-12) Tween (7-9) 6 and under Please let us know the age of registrant 5*Plesae select an age12345678910111213141516171819Sunday Dinner for registrant 5Select YES if you will be joining us for dinner Sunday evening. Dinner is $40.00/person No Yes Will registrant 5 be playing in the Open Golf Tournament? No Yes Handicap for registrant 5Please enter a number from 1 to 56.Purchase mulligans for registrant 5 Mulligans 0 Mulligans 1 Mulligans 2 Mulligans 3 Mulligans 4 Mulligans Is this the first conference for registrant 5?* Yes No Please check the areas that registrant 5 will be willing to provide services for. Workshop leader Discussion Leader Activities Information desk Green Shirts Alateen Preteen Tween How many years has registrant 5 been in AA or Al-Anon? Registrant 5 subtotalRegistrant 6First name of registrant 6* Last name of registrant 6* Email for registrant 6 Badge Name of registrant 6* Does registrant 6 have a different address than Registrant 1? Yes, it is a different address Contact info for Registrant 6Address type for registrant 6* United States Other Address of registrant 6 Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Non-US address registrant 6Please add information for your international address & phone number in the comments field as neededPhone for registrant 6HiddenSection BreakRegistration type for registrant 6 AA Al-Anon AA/Alanon Non-Program Ala-20 (20-29) Alateen (13-19) Preteen (10-12) Tween (7-9) 6 and under Please let us know the age of registrant 6*Plesae select an age12345678910111213141516171819Sunday Dinner for registrant 6Select YES if you will be joining us for dinner Sunday evening. Dinner is $40.00/person No Yes Will registrant 6 be playing in the Open Golf Tournament? No Yes Handicap for registrant 6Please enter a number from 1 to 56.Purchase mulligans for registrant 6 Mulligans 0 Mulligans 1 Mulligans 2 Mulligans 3 Mulligans 4 Mulligans Is this the first conference for registrant 6?* Yes No Please check the areas that registrant 6 will be willing to provide services for. Workshop leader Discussion Leader Activities Information desk Green Shirts Alateen Preteen Tween How many years has registrant 6 been in AA or Al-Anon? Registrant 6 subtotalHandling feeHiddenRegistration fee totalRegistration Fee Total Price: $0.00 Conference Information Opt-In Yes, I would like to receive my conference registration packet via email. Yes, I would like to receive annual information by email about the conference and receive updates about this year’s conference. Please note that we only anticipate that this will result in a total of 2-3 emails per year from the conference.
