2015 TOSHIBA CONNECT REGISTRATION
April 26 - May 1, 2015
Please use this form to register for the event. When you are finished, click the Submit button located at the bottom of the form. Press the "Back" button on your browser to discard your changes or return to the previous page.
The fields indicated with an asterisk (
*
) are required to complete this transaction; other fields are optional. If you do not want to provide us with the required information, please use the "Back" button on your browser to return to the previous page, or close the window or browser session that is displaying this page.
Attendee Information
Attendee Type:
*
Toshiba Employee
Client
Business Partner
Other
First Name:
*
Last Name:
*
Company:
*
Job Responsibility / Title:
Business Address Line 1:
*
Business Address Line 2:
Business Address Line 3:
City:
*
State / Province:
*
Alabama
Alaska
Alberta
Arizona
Arkansas
British Columbia
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
New Foundland
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northwest Territories
Nova Scotia
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Prince Edward Island
Quebec
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming
Yukon Territory
None
Zip / Postal Code:
*
Country:
*
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Taiwan
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Telephone:
*
Tie Line:
E-mail:
*
Company-specific email must be provided. Please no third party emails such as Gmail or Hotmail
Badge Information
Your name as indicated below will appear on your badge and roster. If you wish to change any information, please do so in the appropriate place.
First Name:
Last Name:
Hotel Information
Hotel accommodations will be secured for you by Toshiba based on the information below.
Please do not contact the hotel directly regarding your room reservation.
Use the "Comments" section below to communicate any special requirements to the Toshiba meeting planners.
Daily room rate at the conference hotel:
US $189.00/night (plus applicable taxes/service fees)
Is a hotel room required?
*
Yes
No
Hotel Name:
Gaylord Opryland Resort & Convention Center
, 2800 Opryland Drive, Nashville
Hotel Check-in:
*
4/25/2015
4/26/2015
4/27/2015
Hotel Check-out:
*
4/28/2015
4/29/2015
4/30/2015
5/1/2015
Comments:
Special Dietary Requirements:
Gluten free
Halal
Hindu vegetarian
Kosher
Vegetarian
Enrollments received after Friday, March 31, 2015 cannot be guaranteed a room at the conference hotel.
*** Th
e
Gaylord Opryland may acco
mmodate reservation requests for early arrival and extended departure dates at the Toshiba negotiated room rate, based on availability. For extended stay reservations or questions concerning your reservation, please contact:
[email protected]
In order to secure a hotel room, you will be required to enter credit card information.
In the event you cancel less than 72 hours in advance, a no-show fee will be charged by the
Gaylord Opryland Hotel.
Registration Information
Your registration fees include meeting materials and food/beverage for all schedule events. Travel and hotel expenses are the responsibility of the atten
dees.
Registration fees do not include entry into Focus Group, additional fees apply.
$595 per person by February 27, 2015
$649 per person after February 27, 2015
$695 per person for registration on site
All cancellations must be received in writing to
[email protected]
.
A complete refund of tuition fees will be issued if received by March 31, 2015; however, replacements for registrants may be made at any time without penalty.
Below is the tuition charges you will incur:
Registration Fee:
$595
Focus Group Registr
ation
Focus Group Selection:
*
Not attending
Application Focus Group - $150
Self Checkout Focus Group - $150
Both Application and Self Checkout Focus Groups - $275
All cancellations must be received in writing to
[email protected]
. A complete refund of tuition fees will be issued if received by March 31, 2015; however, replacements for registrants may be made at any time without penalty.
Financial Information
Card Type:
*
American Express
Visa
MasterCard
Discover
Card Number:
*
Card Identification Number:
*
Need help?
Expiration Date:
*
01
02
03
04
05
06
07
08
09
10
11
12
/
2014
2015
2016
2017
2018
2019
2020
2021
2022
Name on Card:
*
PLEASE NOTE: If paying by credit card, the tuition charges on your credit card statement will appear from Omnience, the registration company handling the conference billing on behalf of Toshiba Connect. Hotel charges will be handled separately by the Gaylord Opryland Hotel. You will receive an email receipt once the credit card transaction has been processed. All payments are required to be processed prior to the start of the conference.
Spouse Attending Reception
Spouse fee to attend Tuesday, April 28th Reception: $100 per person
Spouse Attending Reception:
*
No spouse attending reception
Tuesday, April 28th Reception - $100
Spouse First Name:
Spouse Last Name:
*** Please note:
We will be unable to process a refund should your spouse be unable to attend.
Fee is for reception only - other meals are for Toshiba Connect attendees only.
Additional Questions
Are you an employee of a Government Owned Entity?
*
No
Federal Government
State/Provincial
Local
Public Health
Public Education
Utilities
Other (Please specify)
Please enter Other type:
Are you a Lobbyist?
*
No
Yes
If yes, check all that apply:
Procurement
Legislative
Executive
Emergency Contact Information
Contact Name:
Relationship:
Daytime Phone:
Evening Phone:
Notice and Choice Statement
Data entered may be used by Toshiba to provide you with information about other offerings. If you prefer not to receive such information by any means, please check box.
Please do not use this data to send me information about other offerings.
As an attendee, you are participating in sessions at which Toshiba may present confidential information related to development activity for Toshiba hardware, software and services. You agree to hold all such information at these sessions in trust and confidence for a period of two years from the date of disclosure and if applicable, will limit the dissemination of this information within your organization to personnel who have a “need to know”. This restriction shall not apply to information previously known to the attendee, rightfully acquired from third parties, independently developed, or subsequently publicly disclosed by Toshiba.
Be aware that Toshiba does not wish to receive from the attendee, and the attendee agrees not to disclose to Toshiba or its representatives, any internal or restricted information. Accordingly, all information received from the attendee by Toshiba or its associated companies' representatives at these sessions shall be deemed to be in the public domain.
By clicking "Submit" you agree
to the terms and conditions set forth above.
If you have questions about this form, please email
[email protected]
.