Please note that all fields marked with a * are required. You will not be able to submit the form if you leave a starred field blank.

Speaker's First Name *	Speaker's Last Name *
Professional Designation	Title

Company *

Address *

City *	State *	ZIP *

Office Phone *	Cell Phone *

E-Mail Address *

If you have an assistant who should be copied on all correspondence, please provide:

Assistant Full Name
Assistant Phone
Assistant E-Mail

If you will have a co-presenter, please provide the following information:

Co-Presenter's First Name	Co-Presenter's Last Name
Co-Presenter's Professional Designation	Co-Presenter's Title

Co-Presenter's Company

Co-Presenter's Address

Co-Presenter's City	Co-Presenter's State	Co-Presenter's ZIP

Co-Presenter's Office Phone	Co-Presenter's Cell Phone

Co-Presenter's E-Mail Address

Presentation Information

Please give serious thought to your session topic, title, session description and session introduction. If you are selected as a speaker, this information will be used for promotional purposes and may not be changed later.

Title of Presentation (Limit 10 words or less) *

Description of Presentation * (This is in paragraph form. Please do not use bullets, numbered items, or any HTML in your description)

Biographies

Briefly list experience and accomplishments that relate specifically to your topic. Please remember that this is the information that will be used in TALI promotional materials, and al to introduce you as a speaker.

Main Speaker Bio * (This is in paragraph form. Please do not use bullets, numbered items, or any HTML in your description)

Co-Presenter Bio (if applicable) (This is in paragraph form. Please do not use bullets, numbered items, or any HTML in your description)

Audio-Visual

All rooms will be equipped with the following:

• LCD Projector for PowerPoint

• Screen

• Wireless Lavaliere Microphone

• Podium

• Laptop computer must be provided by the speaker

Other audio-visual equipment may be available by special request and may incur an equipment charge. Note that flipcharts are discouraged due to room size. Please indicate your request for special equipment below, and in the event you are invited to speak, a TALI staff person will contact you.

Additional audio-visual equipment requested

Handouts

Attendees tell us how much they appreciate having hard copy handouts in the sessions for notes, etc. Do you plan to supply handouts for your session?

Please select Yes No *

Acknowledgement

If selected, I understand that I will not receive a fee or expenses paid for my presentation. I agree to adhere to the schedule furnished by TALI. I understand that my presentation is not a showcase for promotion of my business, practice or product, and I will not "sell" my products and/or services from the TALI speaker platform. I understand that TALI is not responsible for shipping and/or printing charges. I agree to follow the regulations set forth in this agreement.

If you agree to TALI's terms, please type our full name below and indicate your agreement by checking the box.

Presenter's Full Name *
You must check this box to indicate your agreement to TALI's terms. *