Name* Title Company/Firm Name Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email PhoneHow Did You Hear About This Conference (Eagle Member Name or Other Communication)? Do You Require a Hotel Room (register by August 10th): Yes No Hotel Arrival Date MM slash DD slash YYYY Hotel Departure Date MM slash DD slash YYYY Special Hotel RequestsNOTE: Room reservations are made by completing this form and emailed to Terri Napolitani, not directly with the hotel. Payment will be made by presenting a credit card at check-in. Room Rate: $239 Check In: 3PM Check Out: 12PMWill you be attending the seminar? Yes No Will you be attending the reception? Yes No Will you be attending dinner? Yes No Adjuster CE Credits pending for Florida and Texas. Please provide the following information for ADJUSTER CE CREDITS:Name as it Appears on Your License Florida License # Texas License # Legal CE Credits pending for Pennsylvania, Illinois and and Wisconsin. Please provide the following information for LEGAL CE CREDITS:Name as it Appears on Your License Pennsylvania License # Illinois License # Wisconsin License #
