First Name *

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Last Name *

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Company *

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Address *

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City/Town *

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State *

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ZIP *

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Country *

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Email Address *

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Phone Number *

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What is the name of your panel? *

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How much time is needed for your panel? *

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Please list the name and email addresses of any co-presenters or panel members. *

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Please describe your panel in 250 characters or less:

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Please list your credentials and/or professional experience or just a good reason why your presentation is a good fit for GaymerX:

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GaymerX Panel Submission