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	  #:	  _______________________________