Register Today Step 1 of 6 16% Name(Required) First Last Current Date(Required) MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench 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MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Main Contact Work Phone(Required)Main Contact Cell Phone(Required)Email Employer Name Employer Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Employer Website Employer PhoneEmployer Fax Please check the proper category Catetory 1 - I am licensed or a qualified embalmer in the states listed I am an apprentice embalmer in the state or country of: I am a Mortuary Science Student currently enrolled at: State/Country Where Licensed(Required) Number of Years You've Been Qualified(Required) License Number(Required) Please lists state or country:(Required) Please list the name of the school where you are enrolled:(Required) Please Note: Mortuary Science Students must provide a letter from school or photo ID that acknowledges enrollment in an accredited Morturary Science program. Place a check mark in your attence category. Remember, To qualify for Early Bird Discounted Registration you must register before July 1, 2022.All persons attending (except non-licensed spouses) will pay a registration fee. The amount will be dependent on their category. Category 1: Licensed or Qualified Embalmers & Apprentice of Inern Embalmers: Full Conference - Before July 1st, 2022 = $695.00 Full Conference - After July 1, 2022 = $795.00 Daily Rate = $495 (Please note days in the comments section at the bottom of this form) Category 2: Mortuary Science Students Full Conference - Before July 1st, 2022 = $295.00 Full Conference - After July 1st, 2022 = $395.00 Daily Rate = $175.00 (Please note days in the comments section at the bottom of this form) Please Note: Must provide proof of apprenticeship. Please upload proof at the bottom of this form.Category 3: Apprentice Embalmer Full Conference - Before July 1st, 2022 = $495.00 Full Conference - After July 1st, 2022 = $595.00 Daily Rate = $250.00 (Please note days in the comments section at the bottom of this form) Please Note: Must provide proof of apprenticeship. Please upload proof at the bottom of this form.Category 4: All other persons not in categories 1, 2, or 3 listed above. Full Conference - Before July 1st, 2022 = $695.00 Full Conference - After July 1st, 2022 = $795.00 Daily Rate = $490.00 (Please note days in the comments section at the bottom of this form) Please Note: Must provide proof of apprenticeship. Please upload proof at the bottom of this form.Category 5 - Non-Licensed Spouses: There is no registration fee for spouses, but additional attendees will be asked to pay a minimal fee for any unsponsored meals. This fee may also be paid at the door on the day of the event. Friday lunch - $50.00 Refund Policy(Required)If you need to cancel, call FNA at (417) 833-5130 or email Vernie R. Fountain at vrfountain@earthlink.net to request a refund. If you cancel 2 days or more prior to the beginning day (July 28, 2022) of the conference you will recieve a 100% cash refund. If you cancel less than 2 days before July 28, 2022, or at some time after the conference begins, the refund will be prorated. No Show's or no contacts with FNA requesting cancellation will not be elligible for a refund. Refunds will be mailed to you within 30 days of the close of the conference. FNA, may at it's discretion, offer a 100% cash refund for any cancellation situation. In the event of acts of God or conditions out of the control of FNA and the conference is cancelled by FNA a 100% refund of registration fees will be offered. No reimbursement for any other personal expenses will be offered to registrants. I understand and agree to these terms. I am registering to attend the 2022 International Embalming and Reconstructive Surgery Conference for Professional Embalmers in Springfield, Missouri, USA and aknowledge that I have read and understand the registration and refund policies for this conference. Clicking the word "YES" below will serve as my electronic signature and will be binding.(Required) YES I agree to mail a check, money order, or travelers check payable to Fountain National Academy.(Required)Address to mail registration fees: Fountain National Academy: 2211 West Norton Road Springfield, Missouri 65803 (Once check is received, FNA will email you a confirmation and receipt.) *Credit cards are accepted, but you mus call FNA at (417) 833-5130 to give your card information. I AGREE Select AllAdditional InformationFile Drop files here or Select files Max. file size: 2 MB, Max. files: 5.