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 September 8th): 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, not directly with the hotel. Payment will be made by presenting a credit card at check-in. Room Rate: $359 for King or $409 for Executive King. 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 the dinner? Yes No Entree Choice: Beef Fish Vegetarian Adjuster CE Credits pending for Florida and Texas. Please provide the following information:Name as it Appears on Your Adjuster License Florida Adjuster License # Texas Adjuster License # Legal CE Credits pending for Illinois and Wisconsin. Please provide the following information:Name as it Appears on Your Legal License Illinois Legal License # Wisconsin Legal License # Do you require a Certificate of Attendance to submit to your Bar as an individual? Yes No
