Name* Title Company/Firm Name Spouse's Name (if attending) 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 20th): 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: $439 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 dinner? Yes No Adjuster CE Credits pending for Florida, Oklahoma and Texas. Please provide the following information for ADJUSTER CE CREDITS:Name as it Appears on Your License Florida License # Oklahoma License # NPN # Texas License # Legal CE Credits pending for Illinois, New York and Wisconsin. Please provide the following information for LEGAL CE CREDITS:Name as it Appears on Your License Illinois License # New York License # Wisconsin License #
