ACIP Speaker Information Form

- Please complete this form by Monday , April 27th.
- Contact us ASAP if you have a question about the schedule.
- Please note any field with a * is required.
Name
First Last
If you are receiving a speaking fee, please provide SS# or Tax ID#
Make check payable to
Mail Payment to
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Cell Phone*
Can we use text messaging?*
Email*
Do you need a ride from the airport?
Airline and flight number
Arrival Date
Date Format: MM slash DD slash YYYY
Arrival Time

: HH

MM
Departure Date
Date Format: MM slash DD slash YYYY
Departure Time

: HH

MM
Do you need a ride to the airport?
I will have handouts for my session(s)
Audio Visual Needs - please check all that apply
- Power Point
- Flip Chart
- Other - please describe below
(microphone provided)
Please let us know any additional information or requests
Please type full name below*
I have reviewed the 2015 ACIP Denver schedule and confirm the mutually agreed upon time(s) and date(s) that I am committed to speak are correct.
Please type full name below*
I acknowledge I am an independent contractor for True North Sports, as a speaker at the 2015 ACIP and I accept the mutually agreed upon speaking fee designated in my Faculty Details email I received the week of April 13, 2015.
Thank You!

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