Premier Entertainment

Online Registration Form

E-mail: (required field)	Event:
Name: (required field)	Venue:
Street Address:	Any Additional Address Information:

City:

State/Prov:

Zip/Postal:

Home Phone:

Business Phone:

Mobile Phone:

Verify E-mail:

How many days are you attending? Please make a selection:

If you are purchasing a Daytimers Pass skip the Room Choices!

Select Room Rate & Bed Choice:
There are only Deluxe rooms! Choose either two double beds or one King size bed.
Single Rate Double Rate Triple Rate Quad Rate	2 Double Beds 1 King Bed	Which is more important: Type of Room Near Your Group I am a smoker, please put me near exit

Please list Names/Group you wish to sit with:

Please give the names of your Roommates:

Please list special needs or diet requirements:

Section For Daytimer Passes Only

Friday & Saturday Daytimer Passes:

$75 per person for each day
MEAL TICKETS CAN BE PURCHASED

Are you going to be a Daytimer: Yes No

Please choose the day(s) you are coming:
Friday $75 Saturday $75 Both $150

Credit Card Information

Card Number:

Exact Name on Card:

Exp. Month:

Year:

3-Digit:

Card Type:

Deposit:

# Of People:

(Minimum Deposit of $60.00 per person)

The e-mail created and sent to Alan Kohn when you submit this form goes to E-mails Servers required to be H.I.P.A. compliant. This refers to what is known as the Health Information Protection Act. It requires that there be a 128 bit encryption in all e-mails coming and going from the e-mail servers.

* * Important Note:
When you click on the 'Submit to Alan Kohn' button, it will then send an e-mail to Alan Kohn at this e-mail address: registration@premiereentertainment.org. The next and final thing that happens is that you will be taken to an 'Online Registration Confirmation' page. If none of this occurs then the information was not sent to Alan Kohn and your credit card has not been processed. If that happens you can try to submit the form again or please contact Alan Kohn directly at alankohn@premiereentertainment.org