Registration Logic Step 1 of 8 12% Name* First Last Title* Phone*Email* Address* Street Address Address Line 2 City State Choose Your StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP / Postal Code* Please select your current relationship with PSST:* Business Partner ($475) KEEIS or LEEIS Consortium Member ($375) Non-Profit K12 Public Education ($475) All Others ($475) Organization Name* District Name* Consortium Membership* KEEIS LEEIS In what State is your District*Choose StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingNo. of Employees:*Choose Amount50 - 500501 - 10001001 - 20002001 - 50005001 - 10,00010,001 - 20,00020,001 & AboveSelect one (1) service that best describes your Organization:* Benefits Administrator Third-Party Administrator Payroll Service Human Resources Services CPA Attorney/Legal Firm Select one (1) service that best describes your Organization:* Benefits Administrator Third-Party Administrator Payroll Service Human Resources Services CPA Attorney/Legal Firm For-Profit Education Provider Please describe your service* Please indicate your Partner Status:*Choose oneFull PartnerReferring PartnerNo. of Students:*Choose Amount1 - 500501 - 10001001 - 20002001 - 50005001 - 10,00010,001 - 25,00025,001 - 50,00050,001 - 75,00075,001 - 100,000100,001 & AboveDoes your organization outsource Payroll?* Yes No Does your organization have a solution for ACA? Yes No If Yes, your solution is:* Please indicate all PSST products your District utilizes:* ACA-Track™ Aesop BDIA SeamlessHR Productivity Suite eStub Seamless Data Portal Report Manager Please indicate all PSST products your Organization utilizes:* ACA-Track™ Aesop BDIA SeamlessHR Productivity Suite eStub Seamless Data Portal Report Manager None Please indicate all PSST products your District utilizes:* ACA-Track™ Aesop BDIA SeamlessHR Productivity Suite eStub Seamless Data Portal Report Manager None What HR or Financial Management System does your District use?* Munis® What HR or Financial Management System does your Organization use?* Munis® Event Registration - All areas apply to All Registrants:Please indicate each of the Sunday Evening hospitality events you will attend (included in registration price): 5:30pm - 6:30pm Welcome Reception 6:30pm - 8:00pm Evening Dinner w/Guest Speaker Please indicate each of the Monday Dining Sessions you will attend (included in registration price): 7:30am - 8:30am Breakfast Buffet in the Exhibit Hall 12:30pm - 1:30pm Lunch Buffet in the Exhibit Hall Please indicate which Monday Breakout Sessions you plan to attend (included in registration price):8:30am - 9:00am* General Session Kick-Off in the Ballroom for All Attendees 9:05am - 10:05am* Marketing ACA KEEIS / LEEIS Legalities of ACA None 10:15am - 11:15am* Legalities of ACA ACA Compliance Advanced Filtering for ACA-Track™ & SDP None 11:25am - 12:25pm* AESOP Training ACA-Track™ Training & Enhancements AESOP Experience None 1:30pm - 2:30pm* Marketing to Municipalities SHR Experience Munis® Training None 2:40pm - 3:40pm* I AM the Brand PSST Academy Debut Munis® Payroll HR None 3:50pm - 4:50pm* Accelerating - ACA Pipeline ACA Feedback Session Munis® Finance None Please indicate each of the following events you plan to attend on Tuesday at Churchill Downs :Select your events: 7:00am - 9:00am 'Dawn at the Downs' with elegant breakfast buffet on a Private Veranda overlooking the track - $50 (includes shuttle) 9:30am - 11:30am Leadership Workshop (event & shuttle included in registration price) 11:30am - 6:00pm 'Day at the Races' with Chef's Table Buffet Lunch and Afternoon Racing (event & shuttle included in registration price) Please select each of the conference packages for which you would like to bring a guest:Choose your conference package(s) Sunday Evening Hospitality Events - $75 (includes Reception, Speaker: Pat Day, and Evening Dinner) 7:00am - 9:00am 'Dawn at the Downs' with elegant breakfast buffet on a Private Veranda overlooking the track - $50 (includes shuttle) 11:30am - 6:00pm 'Day at the Races' with Chef's Table Buffet Lunch and Afternoon Racing - $125 (includes shuttle) All Day Combo - 'Dawn at the Downs' & 'Day at the Races' - $150 (includes shuttle & $25 Savings!) Guest's Name* * I have read and agree to the terms stated below as they pertain to Cancellations, Refunds, Legal Release, and Permissions. Total $0.00 QUESTIONS ABOUT REGISTRATION? Call PSST, Monday through Friday, 8:30 a.m. to 5:30 p.m. (Eastern) at: 1-800-488-7395 or 1-502-244-9280. PAYMENT Payment is due in full no later than 04/27/16. Upon completion of registration, you may pay by credit card using the link provided, or by check upon invoicing. A $3 service fee will be applied to all credit card transactions. Checks should be made payable to: PSST LLC 303 N Hurstbourne Pkwy, Suite 110 Louisville KY 40222 CANCELLATION/REFUND OF REGISTRATION Cancellations/Refunds prior to 04/01/16 will incur a $50 processing charge per Registrant and Guests. Cancellations thereafter are non-refundable. All cancellations/refunds must be submitted in writing via the email or mailing address below. Please include the following information for each Registrant and/or Guest: Full Name Date of Registration Payable To Payee Mailing Address Email To: firstname.lastname@example.org – or – Mail To: PSST LLC Conference Refunds 303 N Hurstbourne Pkwy, Suite 110 Louisville, KY, 40222-5143 *Refund requests will be processed upon completion of the Conference. LEGAL RELEASE AND PERMISSION STATEMENT By registering for the PSST 2016 National Leadership Conference, you give PSST and its authorized representatives permission to disclose your conference registration information to any hotels where PSST has blocked hotel rooms for the Conference, for the purpose of handling your hotel reservations and for determining whether PSST’s hotel room block contractual obligations have been met, and you also give such hotels permission to disclose your hotel reservation information to PSST and its authorized representatives for the purpose of determining whether PSST’s hotel room block contractual obligations have been met. You further grant PSST LLC and its authorized representatives; permission to publish, distribute, broadcast, televise, promote, license, sell and copyright for any and all lawful purposes; any photograph and/or digital images, videotape, or sound recording, produced by or on behalf of PSST LLC and its authorized representatives, or under its sponsorship. The afore-mentioned may be used for such purposes as publicity, illustration, advertising and Web content. You also authorize the use of any printed material in connection therewith or with the use of your name and/or identity through descriptive text or commentary in connection with any text or image(s). You release and hold harmless on your behalf, all claims against PSST LLC and its employees/representatives,regarding copyright ownership, publication and right to privacy. You agree you shall receive no fee(s) and all rights, title, and interest to the above materials and their use, belong to PSST LLC. You understand and agree these materials may be duplicated or distributed with or without charge, and/or altered in any form or manner without future/further compensation or liability, in perpetuity.