Name*Spouse (if attending)Company NameTitleAddress 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 Sept. 3rd): Yes No Hotel Arrival Date MM slash DD slash YYYY Hotel Departure Date 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: $409 Check In: 4PM Check Out: 12PMWill you be attending Lunch and Seminar? Yes No Will you be attending Cocktail Reception? Yes Yes, with spouse No Will you be attending Dinner? Yes Yes, with spouse No List any food allergies: CONFERENCE FEES: ComplimentaryLEGAL CE: Credits pending for Pennsylvania, Illinois and Wisconsin. Please provide the following information for LEGAL CE CREDITS.Name as it Appears on Your LicensePennsylvania License #Illinois License #Wisconsin License #Do you require a Certificate of Attendance to submit to your Bar as an individual? Yes No Adjuster 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 #
