Speaker Registration Form

October 9-12, 2016
The Fairmont Scottsdale Princess, Scottsdale, Arizona

Please complete this form and submit by Sept 2, 2016

For questions, please email [email protected]

^*required

First Name ^*

Last Name ^*

Is this your first attendance at a Q Group Seminar?

YesNo

Nickname for badge ^*

Title ^*

Firm or Affiliation Name ^*

Street Address ^*

City ^*

State ^*

Zip or Postal Code ^*

Country ^*

Business Telephone ^*

Cell Phone ^*

Email ^*

Confirmation Email to go to: ^*

Will Your Spouse/Guest be Attending?

YesNo

Name for Badge Spouse/Guest

Home City & State for Spouse/Guest

Will you be staying at the Fairmont Scottsdale Princess?

YesNo

Alternate Hotel

When will your PAPER be submitted for website posting? ^*

When will your SLIDES be available for website posting? Deadline is Sept 9. ^*

Will you be attending the following reception/dinners?

Sunday evening

YesNo

Monday evening

YesNo

Tuesday evening

YesNo

 

Thank You!