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 September 22nd): 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: $279 Check In: 4PM Check Out: 12PMWill you be attending the seminar? Yes No Will you be attending the reception? Yes No Will you be attending the dinner? Yes No Adjuster CE Credits pending for Florida, Texas and Wyoming. Please provide the following information for ADJUSTER CE CREDITS:Name as it Appears on Your LicenseNPNFlorida License #Texas License #Wyoming License #Legal CE Credits pending for Colorado, Illinois and Wisconsin. Please provide the following information for LEGAL CE CREDITS:Name as it Appears on Your LicenseColorado License #Illinois License #Wisconsin License #Do you require a Certificate of Attendance to submit to your Bar as an individual? Yes No
