IBD Exam Review Course Profile Data (Optional)

Diploma in Brewing Module 3 Title (choose 1)

March 12–21, 2013 □ President; Vice President; Other
MBAA Headquarters • St Paul, MN, U.S.A. Corporal Official
□ Director; Manager; Department
PLEASE COMPLETE THE FOLLOWING AND RETURN WITH PAYMENT TO MBAA HEADQUARTERS Head; Supervisor
□ Brewmaster; Assistant
First Name _____________________________________________________ Middle Initial ___________________ Brewmaster; Brewing Supervisor
□ Plant Manager; Engineer; Line
Last Name ___________________________________________________________________________________ Supervisor; Other Production
Responsibilities
Name Preferred on Name Tag ____________________________________________________________________ □ Chemist, Technologist,
Microbiologist; Lab Assistant,
Present Position/Title ___________________________________________________________________________ Technician
□ Professor; Post Doctorate;
Company Name _______________________________________________________________________________ Graduate Student; Student
□ Director; Association
Business Mailing Address ________________________________________________________________________ Executive; Publisher
□ Technical Sales/Service
____________________________________________________________________________________________ □ Consultant
□ Retired
City ______________________________________ State/Province ______________________________________ □ Other:______________
Zip/Postal Code ____________________________ Country ____________________________________________ Primary Area of Responsibility
(choose 1)
Business Phone ________________________________________ Fax: __________________________________
□ R&D; Product Development
□ Packaging
E-mail _______________________________________________________________________________________
□ Production
□ Purchasing
TUITION FEE (SC40813)
□ Engineering
Before January 11, 2013 After January 11, 2013 □ Quality Assurance/Control
______ MBAA Member US$2,200 ______ MBAA Member US$2,500 □ Environmental, Health & Safety
□ Regulatory
______ Nonmember US$2,500 ______ Nonmember US$2,800 □ Education
______ Course + Membership (US$139) = US$2,339 ______ Course + Membership (US$139) = US$2,639 □ Sales & Marketing
□ Distribution
Payment Options: Tuition must be paid in full prior to the course. □ Other:______________
 Check (U.S. funds only—Payable to MBAA)
Organization Type (choose all
 Charge my:  VISA  MasterCard  American Express that apply)
□ Brewery
Credit Card Number _____________________________________________ Expiration Date _________________ Type Product
□ Major □ Beer
Cardholder’s Name _______________________________________________ Security Code _________________ □ Regional □ Wine
□ Micro □ Liquor
Signature ____________________________________________________________________________________ □ Brewpub □ Cider
□ Contract □ Mead
When you provide a check as payment, you authorize us to use information from your check to make a one-time □ Flavored
electronic fund transfer from your account or to process the payment as a check transaction. Funds may be Alcoholic
withdrawn from your account the same day we deposit payment and you may not receive your check back from your Beverages
financial institution. □ Allied
Product/Service
If you have any special needs, accommodations, or requirements, please indicate them here: □ Barley/Malting
□ Hops/Hop Production
____________________________________________________________________________________________
□ Equipment
____________________________________________________________________________________________ □ Packaging Materials
□ Brewing Adjuncts
Only the first 25 applications accompanied by the tuition fee, paid in full (US funds only), will be accepted. □ Brewing Supplies
Cancellations received at MBAA on or before February 6, 2013, will be issued a credit equal to the registration □ Instrumentation
fee, less $100 processing fee, which will be good for two years toward any MBAA continuing education program. □ Lab Supplies
Notices of cancellation after February 6, 2013, will not be eligible for a refund or credit. MBAA reserves the right □ Engineering Services
to cancel the course if a sufficient number of registrations are not received by February 6, 2013. If MBAA cancels □ Wholesaler/Importer
this course, your registration fee will be refunded in full. In the event MBAA cancels this course, MBAA is not □ Consultancy
liable for any expenses or travel change penalties. By registering for this course, you agree to the cancellation □ Government; Educational &
and refund terms and conditions. The attendee is responsible for booking and paying for their hotel Private Institutions; Research
accommodations. Organizations
□ Professional Association;
If you have any questions, contact the MBAA Headquarters by phone: +1.651.454.7250, website: Publisher; Service Organization
www.mbaa.com, or e-mail: scasey@scisoc.org. MBAA continuing education classes are conducted in a □ Retired
nonsmoking environment. □ Other:______________
Mail or fax completed form with payment to:
MBAA, Attn: Sue Casey
3340 Pilot Knob Road,
St. Paul, MN 55121, U.S.A.
Fax: +1.651.454.0766

Thank you for your registration!