Spring 2016 Speaker Registration Form

April 17–20, 2016
The Fairmont Washington, D.C., Georgetown

Please complete this form and submit by March 2, 2016

For questions, please email kstevens@q-group.org.

Full Name ^*

^*required

Nickname for badge ^*

Title ^*

Firm or Affiliation Name ^*

Street Address ^*

City ^*

State ^*

Zip or Postal Code ^*

Country ^*

Business Telephone ^*

Cell Phone ^*

Email ^*

Will Your Spouse/Guest be Attending?

YesNo

Name for Badge Spouse/Guest

Home City & State for Spouse/Guest

Please indicate your ARRIVAL and DEPARTURE dates ^*

Will you be staying at the Fairmont Washington D.C. Georgetown?

YesNo

If NO, what is the name of the hotel where you will be staying?

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

When will your SLIDES be available for printing and website posting? Deadline is March 17. ^*

Will you be attending the following reception/dinners?

Sunday evening

YesNo

Monday evening

YesNo

Tuesday evening

YesNo

 

Thank You!