Name*Spouse (if attending)Company NameTitleAddress Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email PhoneEagle Member SponsorDo You Require a Hotel Room at The Goodwin Hotel (register by September 24th):YesNoHotel Arrival Date Date Format: MM slash DD slash YYYY Hotel Departure Date Date Format: MM slash DD slash YYYY Special Hotel RequestsNOTE: Hotel 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: $229 Check In: 3PM Check Out: 11AMOctober 18: Will you be attending the Reception and Dinner? (By Invitation)YesYes, with spouseNoOctober 19: Will you be attending the Seminar?YesNoOctober 19: Will you be attending the Reception/Lunch?YesNo CONFERENCE FEES: ComplimentaryLEGAL CE: Credits pending for Connecticut, Illinois and Wisconsin. Please provide the following information for LEGAL CE CREDITS.Name as it Appears on Your LicenseConnecticut License #Illinois License #Wisconsin License #Do you require a Certificate of Attendance to submit to your Bar as an individual?YesNoAdjuster CD Credits pending for Florida and Texas Please provide the following information for ADJUSTER CE CREDITS.Name as it Appears on Your LicenseFlorida License #Texas License # This iframe contains the logic required to handle Ajax powered Gravity Forms.