BLACK
HAT
REGISTRATION
UPDATE
FORM
Please
complete
this
form
and
fax
it
to
415/947-‐6011.
If
changes
are
needed
while
an
event
is
taking
place,
please
bring
this
form
on-‐site
to
the
Customer
Service
desk.
Date:
_______________________
Confirmation
#:
(Located
on
receipt
or
invoice)______________________________________
Registrants
First
Name:
_________________________________
Last
Name:
________________________________________
Conference:
_____________________________________________________________________________________________
Requested
Change:
Please
note
that
all
changes
are
subject
to
conference
terms
and
conditions.
Deadlines
for
cancellations
will
be
enforced;
please
refer
to
your
confirmation
receipt
for
specific
cancellation
dates.
___
UPGRADE:
Change
current
pass
to:
_______________________________________________________________________
Please
include
credit
card
payment
details
below
to
pay
for
the
cost
difference
___
DOWNGRADE:
Change
current
pass
to:
____________________________________________________________________
If
a
refund
is
due,
the
cost
difference
will
be
refunded
via
the
same
method
as
the
original
payment
___
TUTORIALS/SUMMITS/WORKSHOPS:
Change/Add
to:
________________________________________________________
___
CANCELLATION:
Please
note
that
all
cancellations
are
subject
to
a
fee.
Please
refer
to
your
original
receipt
for
details.
___
SUBSTITUTION:
Enter
new
registrant
information
below
and
provide
signature
of
original
registrant
who
is
making
the
request:
New
registrants
first
and
last
name:
______________________________________________________________________________
Email:
______________________________________________________________________________________________________
Job
Title:
___________________________________________________
Company:
________________________________________
Address:
____________________________________________________________
Phone:
_________________________________
City,
State,
Zip/Postal
Code/Country:
_____________________________________________________________________________
I
request
and
authorize
the
above
substitution
to
be
made
to
my
registration.
Signed:
_______________________________________________________________________________________
Printed
Name:
_________________________________________________________________________________
Other
Request:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
PAYMENT
INFORMATION:
(Circle
credit
card
choice)
VISA
MASTERCARD
AMERICAN
EXPRESS
Credit
Card
Number:
___________________________________________________
Expiration
Date:
_____________________
Cardholder
Name:
__________________________________________
Amount
To
Charge:
_____________________________
Cardholder
Signature:
_____________________________________________________________________________________
Cardholder
Billing
Street
Address:
_______________________________________
City:
________________________________
State:
___________________
Zip/Postal
Code:
___________________________
Country:
_____________________________
-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐
Office
Use
Only:
Date
Processed:
______________________________
Initials:
________________________
New
Conf
#:
_______________________________
