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 PhoneEagle Member SponsorDo You Require a Hotel Room at The Goodwin Hotel (register by September 24th): 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: $229 Check In: 3PM Check Out: 11AMOctober 18: Will you be attending the Reception and Dinner? (By Invitation) Yes Yes, with spouse No October 19: Will you be attending the Seminar? Yes No October 19: Will you be attending the Reception/Lunch? Yes No CONFERENCE FEES: ComplimentaryLEGAL CE: Credits pending for Connecticut, Illinois and Wisconsin. Please provide the following information for LEGAL CE CREDITS.Name as it Appears on Your LicenseConnecticut 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 #
