1. Your First & Last Name:
2. Region:
Please select Region 1 (CT, MA, ME, NH, RI, VT) Region 2 (NJ, NY PA) Region 3 (DE, DC, MD, VA, WV) Region 4 (KY, NC, SC, TN) Region 5 (AL, FL, GA, MS, VI, PR) Region 6 (MI, OH) Region 7 (IL, IN, WI) Region 8 (IA, MN, NE, ND, SD) Region 9 (AR, KS, MO, OK) Region 10 (LA, TX) Region 11 (AZ, CO, NV, NM, UT, WY) Region 12 (AK, ID, MT, OR, WA) Region 13 (CA, HI, Guam)
3. State:
Please select Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland and Labrador North Carolina North Dakota Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Sasketchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon
4. Will you be attending the event?
Yes No
Event Information: (required: If you do not know the information at this time, please type "unknown" in each box.)
When: 5a. Start Date
5b. End Date
5c. Time (ex. 5 p.m.)
Where: 6a. Address of Event Location
6b. Event Web Site (optional)
Who: 7a. Contact Name
7b. Contact Phone Number
7c. Contact E-Mail
Additional Information: (optional) This information will help expedite our planning.
8a. If you have an agenda for the event, please upload the file here.
8b. What is the time designated for the Broker Program presentation? (Thirty minutes is recommended for a full presentation. Ten to 15 minutes is recommended for commitee briefings.)
9. Estimated number of attendees:
10. The audience will primarily be...
broker-owners/managers only brokers along with general membership Other:
11. Please list any VIPs, special guests or leadership attending the event.
12. Please identify the nearest major airport:
13. Please recommend transportation to/from the airport and event (cab, shuttle, rental car, etc.).
14. Will the state association reserve a room(s) for the Liaison?
Yes No
14a. Location of hotel:
15. Special instructions or considerations, if any.