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2014 Meetings -- Special Event Information Form
Please note: This form must be completed and submitted by June 24, 2013 to guarantee space. Special Events are scheduled on a first received basis.
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Contact Information:
*Contact Person Name:
*Street Address:
Street Address2:
*City:
*State:
*Country/Region:
United States
United Kingdom
Canada
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua And Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia And Herzegowina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic Of The
Cook Islands
Costa Rica
Cote D'Ivoire
Croatia (Local Name: Hrvatska)
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
France, Metropolitan
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard And Mc Donald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic Of)
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic Of
Korea, Republic Of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia, Former Yugoslav Republic Of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States Of
Moldova, Republic Of
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Kitts And Nevis
Saint Lucia
Saint Vincent And The Grenadines
Samoa
San Marino
Sao Tome And Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovakia (Slovak Republic)
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia, South Sandwich Islands
Spain
Sri Lanka
St. Helena
St. Pierre And Miquelon
Sudan
Suriname
Svalbard And Jan Mayen Islands
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania, United Republic Of
Thailand
Togo
Tokelau
Tonga
Trinidad And Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis And Futuna Islands
Western Sahara
Yemen
Yugoslavia
Zambia
Zimbabwe
*Postal Code:
*Contact Email:
*Contact Telephone:
Contact FAX:
Please enter the sponsoring organization name as it should appear:
*Organization:
Organization Abbreviation:
Abbreviation is optional and for use online and in the event mobile application.
Event Type and Date:
Event Type:
Select an Event Type
Breakfast
Lunch
Dinner
Presidential Address
Coffee Hour
Board Meeting
Cocktail Reception
Other
(Note: Cocktail Receptions cannot begin before 6pm)
For "Other", please enter a specific event type:
Preferred Date:
Select an Event Day
Thursday, January 2nd
Friday, January 3rd
Saturday, January 4th
Sunday, January 5th
Preferred Time:
Please Select a Starting Time
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2
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9
10
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05
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15
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25
30
35
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45
50
55
AM
PM
/
Please Select an Ending Time
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2
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5
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7
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9
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
Event Attendance:
Estimated Attendance:
Is this event by Invitation Only:
No
Yes
Program Listing:
Do you want this event listed in the printed program:
Select
Yes
No
Please provide the exact program listing: (50 words max. wordcount:
)
Date Submitted will determine whether a listing can appear in the printed program.
Special Arrangements:
Room arrangements:
Speakers Table
How many people at the speakers table:
Head Table
How many people at the head table:
Other Room Arrangement
Please detail special room arrangements:
Specific equipment:
Projector
Screen
Other Equipment
If other, please detail:
(Note: Hotels will charge you for these special arrangements.)
Comments/Special Requests:
Use the space below to communicate additional instructions/requests about this event to ASSA staff.