First Name: *

Last Name: *

Preferred First Name on Badge: *

Email: (Please use correct email or form will not process correctly) *

Company Name: *

Street: *

City: *

State: *

Zip Code: *

Work Phone: *

Cell Phone: *

Fax Number:

Emergency Contact Name: *

Emergency Contact Phone Number: *

Benefit Level: *

Spouse / Guest Information:

How many guests will you be bringing: *

Please list their full names:

Hotel Information

*Kovack will be making the hotel reservations for you. Our group room rate is only valid 3 days before and 3 days after our event. If you are planning an extended stay, a room is not guaranteed.

**Please note- If you are unable to attend, please email Mindy Marble at mindy@kovacksecurities.com no later than October 8th. If you do not attend and do not cancel with Mindy, the cost of one night's stay, ($319 plus tax), will be charged against your commissions.

Please check the box to confirm your understanding: *

Yes, I understand.

Will You Need Hotel Room *

Yes

No

Hotel Arrival Date:

Hotel Departure Date:

Room Type:

Special Needs:

Marriott Rewards Number:

Credit Card Information

Credit card information is required for all reservations

unless KSI is paying for the entire stay.

Please provide credit card information using the secured credit card form below:

Credit Type

American Express

MasterCard

Visa

Conference Attendee's Name

Card Holder Name, (as shown on card):

Card Number:

Expiration Date (mm/yy):

ID Number: 🛈

Telephone Number:

Street Address:

City:

State

Zip Code

Meal Information - Monday, 10/24

Attending the Continental Breakfast *

Yes

No

Will a guest be joining you for the Continental Breakfast *

Yes

No

Attending the Buffet Luncheon *

Yes

No

Will a guest be joining you for the Buffet Luncheon *

Yes

No

Attending the Evening Reception *

Yes

No

Guest attending the Evening Reception *

Yes

No

Tuesday, 10/25

Attending the Breakfast Buffet *

Yes

No

Will a guest be joining you for the Breakfast Buffet *

Yes

No

Attending the Buffet Luncheon *

Yes

No

Will a guest be joining you for the Buffet Luncheon *

Yes

No

Attending the Evening Reception *

Yes

No

Will a guest be joining you for the Evening Reception *

Yes

No

Attending the Dinner * 🛈

Yes

No

Bringing guest to Dinner *

Yes

No

* Please Note-because of the high cost of this event, if you register for the dinner and do not attend, the cost for food and drinks of $225 per person will be charged against your commissions.

Please check the box to confirm your understanding: *

Yes, I understand.

Wednesday, 10/26

Attending the Breakfast Buffet *

Yes

No

Will a guest be joining you for the Breakfast Buffet *

Yes

No