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FAX REGISTRATION FORM:
Blockchain and its Potential in Government Training Workshop: A Primer for Government Executives, Managers, and Staff
Wednesday, November 29, 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: _______________________