Kentucky PSC / PHMSA Pipeline Safety Seminar

August 23-24, 2022

Thank you for your interest in the Kentucky Gas Association.

To register for the Kentucky PSC / PHMSA Pipeline Safety Seminar, fill out your company information and add employees or other individuals who are attending the event.

When you have completed the form, review it to make sure the amount and all information is correct. Click the “Submit Registration” button to be directed to PayPal, our preferred payment option.

Kentucky PSC / PHMSA Pipeline Safety Seminar Form

"*" indicates required fields

COMPANY DETAILS

Company Name*

Company Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Company Phone Number*

Company Email Address*

REGISTRATION (Includes Reception and Lunch Both Days)

Individual - $150

($150 after 8/16)

Number of Individuals

Member #1 Name*

Position/Title*

Phone*

Email*

Member #2 Name*

Position/Title*

Phone*

Email*

Member #3 Name*

Position/Title*

Phone*

Email*

Member #4 Name*

Position/Title*

Phone*

Email*

Member #5 Name*

Position/Title*

Phone*

Email*

Member #6 Name*

Position/Title*

Phone*

Email*

Member #7 Name*

Position/Title*

Phone*

Email*

Member #8 Name*

Position/Title*

Phone*

Email*

Member #9 Name*

Position/Title*

Phone*

Email*

Member #10 Name*

Position/Title*

Phone*

Email*

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DISPLAYING VENDOR REGISTRATION (Includes Reception and Lunch Both Days)

(6' Tabletop Includes Registration for One Person)

Displaying Vendor - $375

(Includes Registration for One Individual)
($375 after 8/16)

Number of Displaying Vendors

Displaying Vendor #1*

Position/Title*

Phone*

Email*

Displaying Vendor #2*

Position/Title*

Phone*

Email*

Displaying Vendor #3*

Position/Title*

Phone*

Email*

Displaying Vendor #4*

Position/Title*

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Email*

Displaying Vendor #5*

Position/Title*

Phone*

Email*

Displaying Vendor #6*

Position/Title*

Phone*

Email*

Displaying Vendor #7*

Position/Title*

Phone*

Email*

Displaying Vendor #8*

Position/Title*

Phone*

Email*

Displaying Vendor #9*

Position/Title*

Phone*

Email*

Displaying Vendor #10*

Position/Title*

Phone*

Email*

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Vendor Rep - $150

($150 after 8/16)

Number of Vendor Reps

Vendor Rep #1*

Position/Title*

Phone*

Email*

Vendor Rep #2*

Position/Title*

Phone*

Email*

Vendor Rep #3*

Position/Title*

Phone*

Email*

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SPONSORSHIP

Choose a Sponsorship Level

Reception Sponsor (1 available) - $4,000

Diamond Sponsor - $2,500

Platinum Sponsor - $1,500

Gold Sponsor - $1,000

Silver Sponsor - $500

Bronze Sponsor - $250

No Thank You

Company Name

Contact Name

Phone

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Event Total

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CONTACT

P.O. Box 29 • Murray, Kentucky 42071
Toll-Free: 800.455.9427 • Phone: 270.293.1101 • Fax: 270.489.0061