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Speaker Travel and Workshop Information Form
in
WebForm
Contact Information
Presenter Name:
Full name, please.
Affiliation:
Title:
Contact Phone Number:
Address:
Address Continued:
City:
State:
Zip code:
Email:
Please indicate which conference this is in regards to:
AV Equipment and Supplies
Please indicate what, if any, equipment or supplies if any you will need for your presentation. Check all that apply:
Overhead Projector
TV/Monitor and VCR
Data Projector
Screen
Lectern/Podium
Microphone (lapel)
Slide Projector (carousel)
Cassette Player
CD Player
Laptop *
Chalkboard
Whiteboard
Newsprint
Markers
Paper
Pencils
Table
Easel
Masking Tape
No Equipment needed
*If you have a complex presentation, you may want to bring your own laptop.
If you have any other needs not listed above please list them below:
Hotel
Will you need overnight accomodations?:
yes
no
If Yes, what are your planned dates of arrival and departure
(so that we may reserve a hotel room for you)
Arrival date:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
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25
26
27
28
29
30
31
Year
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Departure date:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
How many people will be staying in the room (including yourself)?:
Do you have any special Lodging Needs?:
e.g., handicap, smoking preference, king bed, etc.
Reimbursement
Will you require travel reimbursement from the conference?:
Yes
No, my company will reimburse me
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