Name:

Organization:

Street Address:

Address (cont.):

City:

State/Province:

Zip Code:

Phone: - -

FAX: - -

E-mail Address:

Description of Conference:

Year Preference: 2008 2009 2010 2011 2012 2013

Month Preference: January February March April May June July August September October November December

Meeting Type: One Day Event Multiple Day Event Summer

Are dates flexible to meet facility availability? yes          no

Overnight Accommodations Needed? yes           no

Anticipated number of people:

Number of people requiring housing:
Single Rm:
Double Rm:

Anticipated meals:
Breakfast
Lunch
Dinner

Number of meeting rooms needed:

Number of concurrent/breakout sessions: