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 April 7th): 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: $189 Check In: 3PM Check Out: 11AMWill 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 Kansas, Illinois, Missouri and Wisconsin. Please provide the following information:Name as it Appears on Your Legal License Kansas Legal License # Illinois Legal License # Missouri Legal License # Wisconsin Legal License # Do you require a Certificate of Attendance to submit to your Bar as an individual? Yes No Producer/Agent CE Credits pending for Kansas and Missouri. Please provide the following information:Name as it Appears on Your Producer/Agent License Kansas Producer/Agent License # Missouri Producer/Agent License #
