2019 57th Annual QCESC Banquet Pre-Registration
The event is on Thursday, February 21, 2019 at Deere & Company Headquarters, 1 John Deere Place, Moline IL. A social will start at 5:00 PM, with the program beginning at 6:30 PM. More details can be found at http://qcesc.org/annual-qcesc-banquet/

Everyone, including students, are cordially invited to attend this annual premier event to celebrate, network and showcase the great Science, Technology, Engineering and Math (STEM) Professionals and STEM educators in the Quad Cities region. The event is being held during Engineer Week (E-week).

You can register up to 8 people with this form. You must fill out all of the mandatory fields as indicated by a * symbol at the end of the field name (i.e. Name *) for the form to be saved and submitted. If you properly fill out the form and submit, you should see a message that says "Thanks - Your response has been recorded and e-mailed to the QCESC. If you don't see this message, you need to update or add missing information which will be highlighted on the form in red color.

After successfully submitting your registration, you will be automatically linked to a site to pay on-line using a credit card or PayPal. (http://qcesc.org/annual-banquet-payment-page/). A confirmation of what you submitted will be e-mailed back to you automatically after you successful submit the form.

We are also offering a tour of the Deere Headquarters from 4:15-5:00.

Name badges will be created based on the names and information typed into the form.

The information you submit will only be used by the QCESC and will not be redistributed or sold.

If you have questions or need further Information, send an e-mail to QCESC.org+Banquet@gmail.com

Email address *
Contact Information for Person Submitting Registration Form
Your First Name *
(example John)
Your answer
Your Last Name *
(Example Smith)
Your answer
Phone Number *
(Form XXX-XXX-XXXX) Will only be used if we need contact you and are able by e-mail.
Your answer
Total Number of People You Are Registering with this Form *
Should be between 1-8, Submit Another Form if More than 8
Your answer
Would you like to attend an optional tour of the Deere Headquarters from 4:15-5:00? *
Required
If you do want to attend the tour, how many in your party will attend it
Your answer
Total $ Amount Due *
($35 per person for adults, $25 for Full-Time Students, $0 Special Guests)
Your answer
How Do You Plan to Pay? *
Choice One
Comments or Questions
If you have any additional comments or questions, please add them to the comment box below including any special dietary restrictions.
Your answer
Registration - Person 1
Fill out information for each person attending up to 8 total
First Name - Person 1 *
Your answer
Last Name - Person 1 *
Your answer
Society Currently Belong To, If Any (IEEE, SAME, SWE, Etc.) - Person 1
Note: Not required to belong to a society to attend banquet
Your answer
Employer or School If Full-time Student - Person 1
Your answer
Cost - Person 1 *
Registration - Person 2
First Name - Person 2
Your answer
Last Name - Person 2
Your answer
Society Currently Belong To, If Any (IEEE, SAME, SWE, Etc.) - Person 2
Note: Not required to belong to a society to attend banquet
Your answer
Employer or School If Full-time Student - Person 2
Your answer
Cost - Person 2
Registration - Person 3
First Name - Person 3
Your answer
Last Name - Person 3
Your answer
Society Currently Belong To, If Any (IEEE, SAME, SWE, Etc.) - Person 3
Note: Not required to belong to a society to attend banquet
Your answer
Employer or School If Full-time Student - Person 3
Your answer
Cost - Person 3
Registration - Person 4
First Name - Person 4
Your answer
Last Name - Person 4
Your answer
Society Currently Belong To, If Any (IEEE, SAME, SWE, Etc.) - Person 4
Note: Not required to belong to a society to attend banquet
Your answer
Employer or School If Full-time Student - Person 4
Your answer
Cost - Person 4
Registration - Person 5
First Name - Person 5
Your answer
Last Name - Person 5
Your answer
Society Currently Belong To, If Any (IEEE, SAME, SWE, Etc.) - Person 5
Note: Not required to belong to a society to attend banquet
Your answer
Employer or School If Full-time Student - Person 5
Your answer
Cost - Person 5
Registration - Person 6
First Name - Person 6
Your answer
Last Name - Person 6
Your answer
Society Currently Belong To, If Any (IEEE, SAME, SWE, Etc.) - Person 6
Note: Not required to belong to a society to attend banquet
Your answer
Employer or School If Full-time Student - Person 6
Your answer
Cost - Person 6
Registration - Person 7
First Name - Person 7
Your answer
Last Name - Person 7
Your answer
Society Currently Belong To, If Any (IEEE, SAME, SWE, Etc.) - Person 7
Note: Not required to belong to a society to attend banquet
Your answer
Employer or School If Full-time Student - Person 7
Your answer
Cost - Person 7
Registration - Person 8
First Name - Person 8
Your answer
Last Name - Person 8
Your answer
Society Currently Belong To, If Any (IEEE, SAME, SWE, Etc.) - Person 8
Note: Not required to belong to a society to attend banquet
Your answer
Employer or School If Full-time Student - Person 8
Your answer
Cost - Person 8
End of Form
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service