INDIANA PROPANE GAS ASSOCIATION 115 West Washington Street, Suite 1690S Indianapolis, IN. 46204

1. Registration Form for Spring Session of CETP, Education, and Workshop Classes for 2013 INDIANA PROPANE GAS ASSOCIATION 115 West Washington Street, Suite 1690S Indianapolis, IN. 46204 Tel: 317-655-4444 Fax: 317-630-1827 REGISTRATION DEADLINE IS February 15th, 2013 ALL CLASSES START AT 8 AM AND END AT 5 PM DAILY Registrant Name ____________________Co. Contact Name ________________________ Company Name _____________________ Co. Street Address: ______________________ City: ______________________ State: ______ Zip: ________ Phone: _________________ Co. Contact E-Mail Address: __________________________________________________ Payment information: Make all checks payable to: Indiana Propane Gas Association, 115 W. Washington St., Suite 1690S, Indianapolis, IN. 46204. The payment can be made with VISA, MasterCard or American Express. Make sure that this completed form accompanies the registration. For credit card payment complete the following: Card number: _______________________________________ Security Code: _____________ Expiration Date: ______________ Signature:__________________________________ Amount: $ ____________ COPY THE NEXT PAGE OF THIS DOCUMENT AND GIVE IT TO THE PERSON GOING TO THE CLASSES. NOTE: Students must know their Company mailing addresses and Company telephone numbers when they arrive for their classes. COPY THIS FORM AS MANY TIMES AS NECESSARY, ONE PER STUDENT

2. (PLEASE PRINT) Registrant Name _________________________________________ Hotel Information: The courses will be held at the Wingate by Wyndham. The rate for Indiana Propane Gas Attendees is $79.00 per night. The student must ask for the Indiana Propane Gas Association rate. Hotels and meals are the responsibility of the student. Contact the hotel directly for reservations. Hotel contact information is 317-275-7000, 6240 Intech Commons Drive, Indianapolis, Indiana 46278. If there are questions about the rate contact Ryan at the hotel. The block of rooms reserved will expire as will the special rate as it gets close to the registration deadline. Driving Directions: From 465 on the west side Of Indy exit at the 71st St. exit. Go west turn left at CLASSES Intech Commons and left again into the hotel. All classes start at 8 AM and end at 5 PM daily. Classes may require a take home assignment. All certified classes require a valid government issued picture ID. COPY THIS FORM AS MANY TIMES AS NECESSARY, ONE PER STUDENT