Speaker Name *

Email Address *

Required entries with every submission*

CONTACT INFORMATION

Mailing address

Office Phone

Mobile Phone

Home Phone

Fax

Assistant's Name

Assistant's Phone

Assistant's Email Address

Please list how you wish to be listed in the program

BIO (List EXACTLY as you wish it printed in the Meeting Program.  Excerpts will be taken for your verbal introduction)

CME

I am seeking CME credit for this meeting 

I am NOT seeking CME credit for this meeting.

TRAVEL

I am driving to and from the hotel (skip ahead to ACCOMMODATIONS)

I am FLYING to and from the hotel (please complete Arrival/Departure info below)

 ARRIVAL

I DO / I DO NOT wish to be shuttled from the airport to the hotel

Airport      Airline

Arrival date      Flight Number      Arrival Time

DEPARTURE

I DO / I DO NOT wish to be shuttled from the hotel to the airport

Airport      Airline

Departure date      Flight Number      Departure Time

ACCOMMODATIONS

I have been told the GPPA will make my room reservation at the hotel. 

I understand I will be making my own room reservation at the hotel. 

I do not need accommodations

Please complete the following in either case,

I will be checking in on

I will be checking out on

GUESTS - Guest expenses are the responsibility of the speaker.  Please list the names of your guests while at the hotel (spouse, children/ages, relatives, guests, etc.)

Name , Relationship , Age (if under 18)

Name , Relationship , Age (if under 18)

Name , Relationship , Age (if under 18)

Name , Relationship , Age (if under 18)

Name , Relationship , Age (if under 18)

ACTIVITIES - sign me and/or my guests up for the following:

THURSDAY

President's Welcome Reception, 6:30 - 8:00pm, number attending

FRIDAY

Cocktail Reception in the Exhibit Hall, 6:00 - 7:30pm, number attending

SATURDAY

Cocktail Party "Al Fresco", 6:00 - 7:30pm, number attending