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 Past Attendee Email Invitation Eagle Member's Name Who Made The InvitationDo You Require a Hotel Room (register by February 16th): 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: $270 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 Dinner Choices: Beef Fish Vegetarian List any food allergy:Adjuster CE Credits pending approved for Florida, North Carolina and Texas. Please provide the following information for ADJUSTER CE CREDITS:Name as it Appears on Your Adjuster LicenseFlorida Adjuster License #North Carolina Adjuster License # HOME STATE ONLYTexas Adjuster License #NPN NumberLegal CE Credits pending for Illinois, Virginia and Wisconsin. Please provide the following information for LEGAL CE CREDITS:Name as it Appears on Your Legal LicenseIllinois Legal License #Virginia Legal License #Wisconsin Legal License #Do you require a Certificate of Attendance to submit to your Bar as an individual? Yes No
