Speaker Confirmation Form

Please fill out the form below carefully. Thank you for your time and we look forward to having you join us!

Name*
Prefix First Last
Contact Information
Email*
Cell Phone (or best number to reach you)*
Assistant's contact information
Please provide the email or phone number of your assistant if that is a more convenient way to contact you.
Program Information
Please enter the following information how you would like it to appear in the symposium program material.
Degrees (Ph.D., J.D., etc)
Job Title*
Affiliation*
High resolution headshot*
Max. file size: 50 MB.
Bio (maximum 250 words)*
Title of Presentation

If you do not have your title, please include it when you send your abstract by June 1, 2019 by the latest.
Please upload your abstract. (Maximum 150 words. Please shorten your original as needed.)
Max. file size: 50 MB.
If you do not have your abstract at this time, please send to nrobertson@eppc.org by June 1, 2019 at the latest.
Other
W-9 form*
Max. file size: 50 MB.
Please upload your W-9 Form in order to process your honorarium.
Will you be using Powerpoint?*
- Yes
- No
Your Powerpoint Presentation file is due no later than June 16, 2019.
Will you be staying at the Cosmos Club?*
- Yes
- No
We have reserved a room for you at the Cosmos Club for 2 nights, June 25 and 26. Please indicate if you will be needing this room. If you need only one night, or would like additional nights at your own expense, please email Natalie Robertson at nrobertson@eppc.org.
Dietary Restrictions
Questions or Comments
Comments
This field is for validation purposes and should be left unchanged.

Thank you!

Contact Information