FIFEC Online Registration

Please fill out the information below to register ONLINE for this year's FIFEC conference.
Please only use this form if you are paying by credit card.

Registration fees:

Through May 1st $155
After May 1st $175
Walk-in (cash or credit card only) $195

Enter your Name and Title as you would like them to appear on your name badge (no designations, please).

First Name *
Last Name *
Title
Company/Organization * (40 chars max)
Address *
City *
State *		Zip Code *
State of Florida DFS Adjuster #
Phone * Format: 4075552000		Ext.
Fax Format: 4075552000	(leave blank if none)
E-Mail *
WIll you attend the Luncheon? (included in registration fee) *	Yes No
Will you be bringing a luncheon guest? *
(An additional charge of $35 for each guest must be added to your registration fee)
COURSE SELECTIONS: (You may only select ONE course for each timeslot - please choose NONE if you are not selecting any classes for a particular timeslot or if you do not wish to attend any classes throughout the conference) * Viewing course selections (at right) will NOT affect or erase the ones you've already chosen.
Weds PM 1	view course selections
Weds PM 2	view course selections
Thurs AM 1	view course selections
Thurs AM 2	view course selections
Thurs PM 1	view course selections
Thurs PM 2	view course selections
Fri AM 1	view course selections
Fri AM 2	view course selections
PAYMENT INFORMATION
Credit Card Type
Credit Card Number (no spaces)
Expiration Date* (Month/Year)
CSV # (3 digit # on back)	(Am Ex users, enter 4-digit code on front of card)
Please provide the name on card and billing address if different from the one above.
Name on Card
Billing Address
City/State/Zip

Please type the code shown in the image: *

By clicking submit, you authorize FIFEC to charge your registration fee to your credit card. Fees are non-refundable.

	Florida Insurance Fraud Education Committee

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