Personal InformationHave You Attended One of Our Previous Meeings?*-- Choose One --YesNoEnter Your User Name in the field below (Returning Members, enter your current Username. Your information will be updated) If you would like to register multiple attendees, select the quantity below and fill out the information in the provided fields.UsernameNumber of Attendees*12345 Attendee #1Name* First Last Organization Name*Attendee #2Name* First Last Organization Name*Attendee #3Name* First Last Organization Name*Attendee #4Name* First Last Organization Name*Attendee #5Name* First Last Organization Name*Registrant InformationEmail* Enter Email Confirm Email Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*Cell PhoneCheck Number (if app.)Promo CodeEnter Code Fee*Public Agency COSIPA Members (Claim Handlers/Supervisors; each attendee) - $100All Other COSIPA Members (each attendee) - $150Non-Member Registrant or Late Registration (at door or 3 days prior) - $200Host a Table of 8 - $800Attendee InformationAttendee 1Attendee 2Attendee 3Attendee 4Attendee 5Attendee 6Attendee 7Attendee 8PaymentPayment Method*PayPalCredit CardPay By CheckPay At DoorPayment SummaryPublic Agency COSIPA Members (Claim Handlers/Supervisors; each attendee) Price: $100.00 All Other COSIPA Members (each attendee) Price: $150.00 Non-Member Registrant or Late Registration (at door or 3 days prior) Price: $200.00 Host a Table of 8 Price: $800.00 Total $0.00 Get Our Updates Yes, I would like to receive your email newsletters Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20172018201920202021202220232024202520262027202820292030203120322033203420352036 Expiration Date Security Code Cardholder Name Please Make Check Payable To: COSIPA 1000 Webster Street Fairfield, CA 94533CommentsThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.