IMSA Online Forms - Registration 2013 Questions???
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IMSA's 118th Annual Conference and 36th Annual School
July 20-23, 2013
Pre-Conference Seminars July 16-19, 2013
The Westin Kierland Resort and Spa
Scottsdale, Arizona

REGISTRATION FORM
*First Name: *Last Name: *Position:
*Agency or Firm *Phone#
*Address *City *State/Prov. *Zip/Postal
*EMail Address Companion(If attending)
Name(s) of Children attending
IMSA Title
    (Please provide title of any International elected or appointed position(s) so you may recieve appropriate ribbins.)    
*Are you a member of IMSA? Yes No (IMSA membership information will be included in your registration packet.)  
SPECIAL SERVICES: Please check here if you require special accommodations to fully participate.    
                             
PRE-REGISTRATION PRICING CLICK HERE FOR REGISTRATION POLICIES
Seminar# Check All that Apply Seminar Name Member Non Member
1A General Registration $ 595 $ 670
1B *Companion Registration $ 500 $ 575
1C *Child Registration 2-18 years old $ 475 $ 550
3 Microprocessors in Traffic Signals Tech $ 900 $ 975
4 Work Zone Temporary Traffic Control Safety Tech $ 615 $ 690
If you have an equivalent to the IMSA Work Zone Certification and plan to take a course in which Work Zone is a prerequisite, please submit proof of your equivalent with your registration form.

6

Traffic Signal Technician Level I $ 575 $ 650
8 Sign and Pavement Marking Tech Level I $ 575 $ 650
9 Roadway Lighting Technician Level I $ 575 $ 650
12 Fiber Optics for Traffic, Fire Alarm and Communication Systems Technician Level I $ 850 $ 925
15 Sign and Pavement Marking Tech Level II $ 675 $ 750
16 Traffic Signal Bench Technician Level II $ 675 $ 750
17 Traffic Signal Construction Tech. Level II $ 675 $ 750
18 Traffic Signal Design/Eng. Tech. Level II $ 675 $ 750
19 Traffic Signal Field Tech. Level II $ 675 $ 750
21 Traffic Signal Inspector Level I $ 675 $ 750
22 Fiber Optics for Traffic, Fire Alarm and Communication Systems Field Technician Level II $ 1,100 $ 1,175
23 Traffic Signal Senior Field Tech Level III $ 475 $ 550
25 Sign and Pavement Marking Sr. Tech Level III $ 475 $ 550
26 Fiber Optics for Traffic, Fire Alarm and Communication Systems Design Technician Level II $650 $725

Please Note: If you enroll in a seminar the exam will be given during the scheduled seminar hours.

PRE-REGISTRATION
PRICING
Registration forms must
be postmarked no later
than Wednesday, July 3
and received at the
International Office no
later than Wednesday,
July 10 to qualify for Pre-
Registration pricing. After
July 10 you will need to
register on-site.
On-site pricing will
increase by $100.00 per
package..

All seminar registration packages include seminar materials, exam fees, lunches and refreshment breaks for the days the seminars are scheduled.


Continuing Education Units (CESs):

The University of Tennessee, Division of Outreach & Continuing Education will award 1 CEU for every 10 contact hours to each participant, who successfully completes their IMSA certification seminar in Scottsdale, AZ. The CEU is a nationally recognized unit designed to provide a record of an individual.s continuing education accomplishments. There will be a onetime charge of $10 per seminar, payable on site. Upon written request, a transcript of this record will be made available as designated by the participant.

Quantity of Challenge Exams (each) $75.00 member, $100.00 non-member - List Title(s):
(For individuals who would like to take the exam without participatig in the seminars)
*Children, spouses, "significant others" and retired members are eligible to participate in the Companion Program.
The Companion Program activities are not available to General Registration and Students.
METHOD OF PAYMENT
*(please choose one)    
Credit Card Card Type: (if applicable)
Check Check Number: (if applicable)
Purchase Order Purchase Order Number: (if applicable)
Form Submission
Comments:
  No Yes * I have read and agree to the Registration Policies
  No Yes * I have read and agree to the Cancellation and Refund Policy