Name*Company NameAddress Street Address City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Email PhoneDo You Require a Hotel Room (register by May 29th):YesNoHotel Arrival Date Date Format: MM slash DD slash YYYY Hotel Departure Date Date Format: 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: $139 or Suite at $179. Check In: 3PM Check Out: 12PMJune 26th - Will you be attending Dinner?YesNoJune 27th - Will you be attending the Seminar?YesNo CONFERENCE FEES: Law Firm Member - $395 Associate Member - $195* *If there is more than one person from a member firm attending this conference, the first person pays the full Law Firm Member Fee ($395) and any additional person(s) from that firm pays the Associate Member Fee ($195). Hotel Room Rate: $139 or Suite at $179 (payable to hotel). Conference fees are payable by check or credit card or ACH Direct Debit from the MEMBERS/ON-LINE PAYMENT dropdown on the website. Eagle Member password is eaglelaw2018. Fees apply for credit card payments (2.9%). If using ACH Direct Debit, you must first register your banking information with Terri before using it. There are no fees to members for using this option. Please make your checks payable to Eagle International Associates and mail to Terri Napolitani, Eagle International Associates, PO Box 371510, Las Vegas, NV 89137-1510. Payment is due by June 19th. Legal CE Credits pending for Illinois and Wisconsin. Please provide the following information for LEGAL CE CREDITS:Name as it Appears on Your LicenseIllinois License #Wisconsin License #Do you require a Certificate of Attendance to submit to your Bar as an individual?YesNoAdjuster CE Credits pending for Florida, Oklahoma, Texas and Wyoming. Please provide the following information for ADJUSTER CE CREDITS:Name as it Appears on Your LicenseFlorida License #Oklahoma License #NPN #Texas License #Wyoming License # NOTE: If you plan to pay online please go to MEMBERS/ONLINE PAYMENT dropdown on the website after you SUBMIT this form below. Thank you. This iframe contains the logic required to handle Ajax powered Gravity Forms.