WMC FLY-In Participant Information
April 12-17, 2015

(NOTE: This form is not yet operational. Please contact Lynne at wearewmc@wmc-usa.org for details about signing up to participate in the Fly-In. The form shows the information you will provide.)

Last name First name Middle Initial
(Middle Initial needed to identify you on the teams.)

Company name Title
Work address:
City State Zip Code Plus Four
Home address:
City State Zip Code Plus Four
Work_phone Cell_phone
(Cell phone needed for contact during the Fly-In with schedule changes)
Email (**Important!**)
Discipline (ie coal, hardrock, vendor, energy, etc.)

Home and Work Congressional Districts
(Look this up by your zip code(s) at http://www.house.gov/representatives/find/)

States you can represent, PLEASE INCLUDE ZIP CODE PLUS FOUR FOR THE SPECIFIC LOCATION (where you live, used to live, where parents live, where your company does business, etc.)

One Washington Circle Hotel confirmation #
Would you like a roommate?
(Hotel charges $20 per day extra for an additional person in room)
Arrival Day and Time
Departure Day and Time
(Arrival and Departures are needed so we know what days/times to schedule appointments for you)
Emergency Contact Name Emergency Contact Cell #