2019 Spring Conference - Speaker Registration
If you are a conference speaker, please fill out the form below.
First Name *
Your answer
Last Name *
Your answer
Title *
Your answer
Organization *
Your answer
Address: *
Your answer
City/State/Zip *
Your answer
Phone: *
Your answer
Mobile Phone: *
Your answer
Email Address: *
Your answer
Title of Presentation *
Your answer
Date/Time of Presentation *
MM
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DD
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YYYY
Time
:
Description of Presentation (3-4 sentences) *
Your answer
Speaker Bio (3-4 sentences) *
Your answer
Audio/Visual Needs (Computer and Projector will be provided). *
Your answer
Will there be handouts associated with the presentation? *
Additional Speakers
Please provide information concerning additional speakers participating in this presentation.
Additional Speaker 1 - First Name
Your answer
Additional Speaker 1 - Last Name
Your answer
Additional Speaker 1 - Title
Your answer
Additional Speaker 1 - Bio
Your answer
Additional Speaker 2 - First Name
Your answer
Additional Speaker 2 - Last Name
Your answer
Additional Speaker 2 - Title
Your answer
Additional Speaker 2 - Bio
Your answer
Cost/Fees
Is there a professional fee for your presentation/workshop? *
If there is a fee, what is the amount:
Your answer
If there is a fee, is it negotiable?
Conference/Presentation Logistics
Projected Arrival Time at Conference: *
MM
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DD
/
YYYY
Time
:
Will you need airport pickup? *
If yes, what date/time will you need airport pick up?
MM
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DD
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YYYY
Time
:
Will you need us to make hotel accommodations for you? *
If yes, which nights (by date) will you need accommodations?
Your answer
If yes, will your agency/organization cover the cost of the hotel room(s)?
Will you be attending the banquet? *
Please list any special diet restrictions: *
Your answer
Please provide any other pertinent information:
Your answer
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