Name*TitleCompany/Firm NameAddress 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 February 10th): Yes No Hotel Arrival Date MM slash DD slash YYYY Hotel Departure Date MM slash DD slash YYYY World of Hyatt Membership NumberSpecial 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: $199 Check In: 3PM Check Out: 11AMWill you attend the seminar? Yes No Will you attend the reception? Yes No Will you attend the social event at the American Jazz Museum following the hotel reception? Yes No Adjuster CE Credits pending for Florida and Texas. Please provide the following information:Name as it Appears on Your Adjuster LicenseFlorida 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 LicenseKansas 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 LicenseKansas Producer/Agent License #Missouri Producer/Agent License #