Check Availability

Form Title
  • Contact Name for Individual Coordinating Speech*
    0
  • Title*
    1
  • Phone*
    2
  • Email*
    3
  • About the Event*
    4
  • Event*
    5
  • Time*
    6
  • Date*
    7
  • Location*
    8
  • Sponsoring Organization*
    9
  • Organization Category*(check the appropriate item)
    Not-For-Profit
    For-Profit
    Public Agency
    10
  • Type of Organization*(check the appropriate item)
    Healthcare Purchaser (Employer)
    Provider
    Hospital
    Pharmaceuticals
    Health Informatics
    Consumer
    Consumer
    Government
    Other
    11
  • Brief Organization Description/History*
    12
  • Topic of Presentation*
    13
  • Presentation*(check the appropriate item)
    Keynote
    Plenary
    Panel
    Other
    14
  • Approximate Number of Attendees*
    15
  • Attendee Classification*(check the appropriate items)
    Employers
    Physicians
    Hospital Executives
    Pharmacists
    Academics
    Health Informatics
    Consumers
    Health Plan Executives
    Benefit Consultants
    Other
    16
  • Expenses Covered*(check the appropriate items)
    Airfare
    Lodging
    Meals
    Other
    17
  • Contact Name for Person Responsible for Expense Reimbursement*
    18
  • Phone*
    19
  • Fax*
    20
  • Email*
    21
  • Mailing Address*
    22
  • How you prefer to receive invoices/receipts*(Please check the appropriate box)
    Fax
    Mailing Address
    23
  • Captchacopy the wordsCheck Availability
    24
  • 25