<p> Encore Customer Registration Form</p><p>Convergence 2015 – March 16 -19, 2015 Atlanta, GA</p><p>To complete the form, simply tab and enter the following information. Submit to: Sharlynn Saull at [email protected] </p><p>All travel to the United States from Canada will require a valid passport. Please visit http://www.ppt.gc.ca/ for more information.</p><p>Authorized Microsoft telephone number (from Voice): XXXXXXXXXX</p><p>Salutation </p><p>First name: </p><p>Last name: </p><p>Name you would like to appear on your conference name badge: </p><p>Email address: </p><p>Title: </p><p>Company name: </p><p>Company address: </p><p>City: </p><p>Province: </p><p>Postal Code: </p><p>Company telephone: (XXX)XXX-XXXX</p><p>Company fax number: (XXX)XXX-XXXX</p><p>Mobile telephone number: (XXX)XXX-XXXX This is how Encore will be in contact with you at Convergence.</p><p>1 Emergency Contact Information</p><p>First name: Last name: </p><p>Daytime phone: (XXX)XXX-XXXX Evening phone: (XXX)XXX-XXXX</p><p>Company Information</p><p>In your organization, what department do you work in? </p><p>What is your primary role in your organization? </p><p>What industry defines your business? </p><p>How many computers are in your organization? </p><p>Additional Information Do you have any dietary requirements or food allergies?  Vegetarian  Vegan  Kosher  Halal  Not Applicable  Diabetic  Other: </p><p>Do you have any accessibility needs?  Visually Impaired  Wheelchair Access  Hearing Impaired  Other: </p><p>Are you a government employee?  Yes  No</p><p>How many people are in your organization? </p><p>How many times have you been to Convergence? </p><p>Microsoft may send me pertinent security, product, and event information via:  Work address  Email  Business phone number</p><p>Microsoft partners may contact me with information about their products, services, and events:  Yes  No</p><p>Convergence speakers may contact me with information about Microsoft products, services, and events: 2  Yes  No</p><p>I would like to receive information about future Convergence events via email:  Yes  No</p><p>Microsoft Convergence Planning Team may contact me regarding activities associated with Convergence 2015 and taking place between the dates March 16 – 19, 2015. Please Note: Opting into this question allows Microsoft to inform you via email about special events & activities.  Yes  No</p><p>Payment </p><p>Before Encore registers customers for Convergence 2015, payment for the conference amount must be received in full . Your Account Executive will advise you of the payment amount and, at that time, please indicate which payment form you will be using (i.e. Visa, American Express, MasterCard, or Discover). Do not email your credit card info.</p><p>Full Conference Pass</p><p>Early Pricing $1,645 USD Standard Pricing $1,945 USD Up! Pass $2,145 USD (Until Jan. 8th, 2015) (After Jan. 8th, 2015) (Available until Jan. 8th, 2015)</p><p>*Day Passes, Experience Center, and Reception Guest passes are also available, please contact us for details.</p><p>I will be paying by: Visa American Express MasterCard Discover</p><p>Credit Card Number: </p><p>Expiry Date: mm/yy</p><p>Name of Cardholder: </p><p>3 Digit Verification Code #: (for AMEX cards it’s the 4 digit number above the card number) </p><p>Booking your hotel </p><p>3 Please be sure to enter the Convergence website and complete your hotel booking after you have received your official confirmation from Microsoft. You can do this, by completing the following steps:</p><p>1. You may review and make changes to your registration information by going to the Registration website. 2. Click on User Name and Password 3. Enter your Username 4. Enter your Password </p><p>PLEASE NOTE: Encore will provide you with your username and password so you can access the returning services portion of the Convergence 2015 website.</p><p>Questions?</p><p>If you have any questions regarding this form or other, please call 888.898.4330.</p><p>4</p>