Lake Charles LA January 2017

Host:  Ron Fogal, Pumpelly Tire
City:   Lake Charles, LA
Date:  January 9-11, 2017
Hotel:  Golden Nugget
Hotel Room Rate: $139/night
Closest Airport:  LCH (Lake Charles) or IAH (Houston) 150 miles

Please Note:
– Guests requiring a separate room should register separately.
– Any changes after this form is submitted should be sent to Pat Brown.

First Name for Name Badge *

Last Name *

Company Name *

Work Address *

Work City/Province *

Work State/Province *

Work Zip/Postal Code *

Work Country *

Cell Phone *

Business Phone

Attendee Email Address *

HOTEL ARRANGEMENTS

Hotel Room Required? * Yes No

Hotel Check-In *

Please change if different.

Hotel Check-Out *

Please change if different.

Bed Type * One Bed Two Beds

Special Hotel Requests

Special Dietary Requirements

AIRLINE ARRANGEMENTS

Are you flying or driving to the destination city? * Flying Driving

Arrival Date *

Arrival Airline & Flight #

Arrival Time 12 1 2 3 4 5 6 7 8 9 10 11 : 00 10 20 30 40 50 AM PM

Arriving From/To:

Example: ORD/MEM

Departure Date *

Departure Airline & Flight #

Departure Time 12 1 2 3 4 5 6 7 8 9 10 11 : 00 10 20 30 40 50 AM PM

Departure From/To

Example MEM/ORD

REGISTER YOUR GUEST

Are you bringing a guest? * Yes, I am bringing a guest No, I am not bringing a guest

Guest First Name for Name Badge

Please leave blank if you are not bringing a guest.

Guest Last Name

Please leave blank if you are not bringing a guest.