TELUSYS CUSTOMER SERVICE CENTER

STEP #1
MAKE YOUR SELECTIONS

STEP #2
CHECK YOUR INFORMATION

STEP #3
REVIEW / PRINT YOUR REGISTRATION

Winter Social
Bristol Bar & Grill 11801 Olive Blvd Creve Coeur, MO 63141 4:30-7:00 pm

Join us as we welcome in the Winter Season!

Date: Tuesday, December 12th, 2017
Time: 4:30-7:00 pm

Interested in becoming a Chapter Member? Complete this form online membership

* All items that are marked with an " * " MUST be provided. All other fields are optional.
*First Name:
*Last Name:
ID#:		(if applicable)
Title / Credentials:
Badge Name:

Company/Organization Name:
*Address 1:
Address 2:
*City:
*State/Canadian Province:		(U.S./Canada)
International Province:
*Zip/Postal Code:		(Required for U.S.)
*Country:

*Phone:
Fax:

*E-mail Address:

Please indicate your Member Status and Registration Selection. It is not necessary to enter credit card or other billing related information if you are a current member of HIMSS or the Midwest Gateway Chapter.

Indicate your Registration Category:

	Member
	Non-Member
	Student

Make your Registration Selections:

SELECT

EVENT / OPTION NAME

Selection
Not Available
During This Time Period

Winter Social

Member:	$0.00
Non-Member:	$30.00
Student:	$0.00

Payment Options:

Select your preferred method of payment and enter your billing contact information. If you are paying by credit card, the billing contact information should be the billing address of the card holder.

Payment information is not required for orders that total zero dollars.

Yes, my billing address is the same as the contact address above.

*First Name:

*Last Name:

Company:

*Billing Address1:

Address2:

*City:

*State *Zip Code (Required for U.S.)

*Country:

*I prefer to pay by check.

Midwest Gateway Chapter of HIMSS

Mail your payment to:

Midwest Gateway Chapter HIMSS c/o Frank Lyerla 745 Homm Street Bethalto IL 62010

*I prefer to pay via Credit Card.

Please Note:

You are making this purchase directly from the Telusys Customer Service Center. TELUSYS will be the only name to appear on your credit card statement for these charges if you select "Pay via Credit Card" as your payment option.

Card Type:

Card Number:

Card Security Code (Security Code Help)
(3 or 4 Digit Number)

Exp. Date:

Month Year

I understand that these charges will appear as charges from "TELUSYS" on my CREDIT CARD STATEMENT. If I am making this purchase using someone else's credit card, I will notify the card holder that a purchase was made from "TELUSYS" and these charges will appear on their CREDIT CARD STATEMENT.