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FAX REGISTRATION FORM:
Latest Information on Government Cybersecurity and Implementing the President's Cybersecurity Executive Order (EO) Training Workshop
Wednesday, November 15, 2017
Willard InterContinental Hotel

Please print this form, fill out completely and fax to 703-683-5480 or mail to:

   Potomac Forum, Ltd.
   c/o: Potomac Management Resources - 400 N. Washington Street, Suite 300 - Alexandria, VA 22314

From: __________________    Organization: _______________________    Phone number: _______________

Registration Information:

First Name: __________________   Last Name: ____________________   Title: ___________________________
Department/Company: _______________________________________________________________________
Agency/Group: _______________________________   Office/Division: __________________________________
Address: ___________________________________________________________________________________
City: ________________   State: ____   Zip Code: ___________
Office Phone: _______________   Office Fax: ____________   Email Address: ____________________________
Type of Company:   __ Government     __ Industry     __ Other (non-profit, academia, etc)

Payment Information:

Registration Fee: $____________ (see www.potomacforum.org)     P.O. Number: ___________________
Payment Method:   Check ____     Training Form ____     Credit Card ____     Promotion Code ____
If paying by Check, please mail to the address above. If paying by Credit Card, please supply the following information:

  • Card Type:   __ MasterCard    __ VISA
  • Card Number: ___________________________________
  • Expiration Date (mm/yyyy): ____/_______     Security Code (on back of card): _______
  • Name on card same as attendee? (Y/N) ___     Name on card: __________________________________
  • Billing Address: __________________________________________________________________________
  • Phone number of cardholder: _____________     Email address of cardholder: _______________________