Membrane Plant Operator Training Registration – MOC-I: Introduction to Membrane Systems – San Jose, CA – July 25-27, 2017 Silicon Valley Advanced Water Purification CenterSan Jose, CA Tuesday-Thursday - July 25-27, 2017 RegistrantSalutation*Mr.Mrs.Ms.Dr.First Name*Middle InitialLast Name*Job Title*Company*Address*City*State*Zip/Postal Code*Country*Telephone*CellFaxEmail Address* Email Notifications*Yes, I authorize receiving publication email notificationsNo, I would not like to receive publication email notifications (opt-out)Authorization for receiving publication email notification from SWMOA. (applies to all email addresses on this form)Website Special Needs Food Allergies (describe in comments) Gluten Free Meals Halal Meals Vegan Meals Vegetarian Meals Wheelchair Access Other (describe in Comments) License #License StateLicense TypeLicense Grade Membrane Operator CertificationThe registration fee includes CEUs/PDHs, the shipment of the MOC Manual to the address listed above upon receipt of full payment. If an alternate address for shipment is requested, please provide the preferred shipping address in space provided below. For payments received within five (5) business days of the school, the MOC Manual will be provided on the first day of class.Limited Space - Registration Reserved ONLY Upon Receipt of Payment and AvailabilityMOC Registration (July 25-27, 2017)*SWMOA Members, $575Non-Members, $650Exam Only, $0Non-Members - Contact SWMOA Membership if interested in joining prior to registering or click here to apply for membership now.MOC Exam Registration (July 27, 2017)*Exam, $25No Exam RequiredShipping MOC Manual to a different address?*Yes, Ship to a different address than listed aboveNo, Ship to the same address listed aboveAlternate Address for the Delivery of the MOC Manual: If the shipment of the MOC Manual is to an alternate address, please provide it here. Please note that a signature is REQUIRED upon delivery (price included).Shipping Address for MOC Manual* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Total $0.00 Payment InformationPayment Method*Credit Card - Online PaymenteCheck (Bank Wire w/o processing fee) - Online PaymentCheckInvoiceIf paying by check: Make checks payable to: Southwest Membrane Operator Association (SWMOA) and mail to: 1035 East Vista Way #103, Vista, CA 92084. CommentsIf you would like a copy of the invoice/receipt sent to another*Yes, send copy of invoice/receipt to:No, don't need a copy sentIf yes, you would like a copy of the invoice/receipt sent to another other than the attendee please enter information below.Name First Last Email Address Comments Written cancellation requests received on or before June 30, 2017 will receive a refund, less a $50 administrative processing fee upon return receipt to SWMOA office of the unaltered MOC Handbook. Without the return receipt of the unaltered MOC Handbook the cancellation fee will be $200 (includes administrative processing fee and handbook fee). Full payment is required if cancellation is received on or after July 1, 2017 - no refunds and no credits for future events will be granted. However, substitutions may be made at any time. SWMOA reserves the right to make changes in programs and speakers, or to cancel programs when conditions beyond its control prevail. Every effort will be made to contact each enrollee if a program is cancelled. If a program is not held, SWMOA’s liability is limited to the refund of the program fee only. Final Step of Application ProcessCaptchaPlease enter the letters displayed above to complete your application and then click Submit.