Speaker Registration Speaker Information 2019 Step 1 of 2 - Personal and Travel Information 0% Personal InformationName for check to be made payable to:* First Last Address for mailing check:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Do you have a Venmo account?*YesNoWould you prefer to have your speaking fees paid via Venmo?*YesNoVenmo Account Information:*Phone Number:*Email* Do you require travel and hotel accommodation?*Yes, I require travel & hotel accommodationNo, I do not require travel & hotel accommodationTravel InformationFull name as it appears on Driver’s License or Identification Card:*Date of Birth:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Departure City/Airport:*Arrival City/Airport:(unless specified otherwise)Departure Date:* Departure Time:*(i.e. before 7am; 7-11am; 11am-1pm; 1-5pm; After 6pm)Return Date:* Return Time:*(i.e. before 7am; 7-11am; 11am-1pm; 1-5pm; After 6pm)TSA-Pre Number:(if you have one)Special Accommodations or Requests Assistance with Wheelchair:*No wheelchair assistance neededCan walk but need assistance to and from gateNeed lift/transfer assistance to and from aircraft seatPersonal Wheelchair Storage:*No wheelchair stowage neededManual wheelchairPowered wheelchair with spillable batteriesPowered wheelchair with non-spillable batteriesNumber of spillable batteries:*Number of non-spillable batteries*Aisle Seat?*(if possible)Yes, I want an aisle seat if possibleI do not require an aisle seatFront of the plane?*(if possible)Yes, I would like to be at the front of plane if possibleI do not require to be seated at the front of the planeBack of the plane?*(if possible)Yes, I would like to be at the back of plane if possibleI do not require to be seated at the back of the planeHotel Accommodation InformationWe cover 2 nights hotel accommodations, any additional nights requested will be at speaker’s expense.Name for reservation:*Check in date:* Check out date:* Special Accommodations or RequestsDo you require a mobility accessible room?*Yes, I require a mobility accessible roomNo, I do not require a mobility accessible roomDo you require a roll in Shower?*I require a roll in showerNo, I do not require a roll in shower1st floor?*I need my room to be on the first floorI do not need my room to be on the first floorRoom beds:*2 Queen beds1 King bedI do not require any special beds in my room Conference InformationBiography and Headshot will need to be received upon signing contract* I agree to provide a biography and headshot when I sign the contract Are you presenting on the main stage or in a breakout session?*Main StageBreakout sessionBothDescription of speaking topic for main stage will need to be received by April 15th, 2018* I understand that I need to provide my speaking topic by April 15th, 2018 Will you have handout materials that need to be printed for your main stage session?*Yes, I need handout materials printed for my main stage presentationNo, I do not need materials printed for my main stage presentationI agree to provide a PDF or Word Document at least 1 month prior to conference date* I understand that I need to provide a pdf or word document for my handout one month prior to event Description of breakout session topic will need to be received by April 15th, 2018* I understand that I need to provide my speaking topic by April 15th, 2018 Will you have handout materials that need to be printed for your breakout session?*Yes, I need a handout printed for my breakout sessionNo, I do not require a printed handout for my breakout sessionI agree to provide a PDF or Word Document at least 1 month prior to conference date* I understand that I need to provide a pdf or word document for my handout one month prior to event Have you authored a book and would like to participate in our book signing?*Yes, I would like to be a part of the book signingNo, I have not authored a bookBook Title(s):*Publishing House Contact Name:*Publishing House Phone Number or Email for Ordering:*Do you plan on having a PowerPoint presentation?*Yes, I will presenting with Power PointNo, I will not be giving a Power Point presentationI agree to submit my powerpoint presentation for testing at least one month prior to the conference date* Yes, I will provide my PowerPoint presentation files at least one month before the conference date After your speaking engagement, would you be willing to stay for 15 minutes after your event to answer specific questions in a private setting?*Yes, I would like to answer questions in a private settingNo, I would not like to take part in a private question/answer settingWill you be joining us for the Speaker Dinner on Friday?*I will be attending the speaker dinner on FridayI will not be attending the speaker dinner on FridayDo you have any allergies that we should be aware of?* No Dairy No Soy Gluten Free Vegetarian Vegan Pescatarian Other No food allergies Please check all that applyMy other allergy is:*Will you be attending the conference as a guest Saturday, Sunday or both days?*I will be attending as a guest on SaturdayI will be attending as a guest on SundayI will be attending as a guest on both daysI will not be attending the conference as a guestWill you be joining us for lunch on Saturday?*I will be attending Saturday lunchI will not be attending Saturday lunchWill you be joining us for lunch on Sunday?*I will be attending Sunday lunchI will not be attending Sunday lunchWould you like to provide contact information for our conference participants to find you?*Yes, I would like to provide contact informationNo, I would not like to provide contact informationThis is optionalContact email WebsiteLinks to social media accounts:Other contact information:Do you have specific accommodations that you require during your time with us that you haven’t communicated or that is not listed?