American Governor Company Analog Focus Class Registration Form 27 Richard Road, Ivyland PA 18974 Phone: 215-354-1144, Fax: 215-354-1782 http://www.americangovernor.com

Woodward Analog Focus Class October 24 - 25, 2017

Registration fee is $2,575.00* per person. VISA and MasterCard accepted.

Fax to 215-354-1782 or email to [email protected]

Attendee Information Attendee 1 Attendee 2 Attendee 3

Name:

Title:

Company:

Plant Name / Location:

Attendee Phone:

Attendee Fax:

Attendee Email:

Attendee Street Address:

City, ST, Zip Code

Country:

Registered By:

Referred By:

Registration Date:

Method of Payment Attendee 1 Attendee 2 Attendee 3

Check or PO Number:

Visa or Mastercard #

Exp. Date (10/17 or Later):

Name on Card:

Cardholder Phone:

Cardholder Fax:

Cardholder Email:

Cardholder Street Address:

City, ST, Zip Code:

Country:

Billing Notes: 1) Invoice (and credit card receipt, if applicable) will be sent to Purchaser. Please indicate whether you prefer invoice sent by Fax / Mail / Email 2) Credit card payments will be charged ten (10) days prior to event. 3) 25% cancellation fee applies to cancellations received within five (5) days of event.

4) Mail check payments to: American Governor Company Attn: Focus Class Registrations 27 Richard Road Ivyland, PA 18974

*Register by July 1st to receive $200.00 off your registration fee!