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 February 24th): Yes No Hotel Arrival Date MM slash DD slash YYYY Hotel Departure Date MM slash DD slash YYYY Marriott Bonvoy Number 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: $234 Check In: 4PM Check Out: 12PMCancellation Policy: Hotel rooms must be cancelled 72 hours prior to check-in for a refund. Afterwards, one night room and tax will be charged.Will 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 for ADJUSTER CE CREDITS:Name as it Appears on Your License Florida License # Texas License # Legal CE Credits pending for Illinois, Pennsylvania and Wisconsin. Please provide the following information for LEGAL CE CREDITS:Name as it Appears on Your License Illinois License # Pennsylvania License # Wisconsin License # Do you require a Certificate of Attendance to submit to your Bar as an individual? Yes No
