Speaker Questionnaire1 About You2 About Your Presentation3 Accommodations4 Terms & ConditionsSpeaker's Name*Title/Position*Company/Organization Name (if applicable)*Email* Mailing Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Your Photograph*Provide a photograph (high resolution preferred) for use in marketing your presentation.Provide a biography*I will upload a document.I will enter my Biography below.I will provide a link to an online Biography.Let us know how you'd like us to introduce you to our members.Please upload a copy of your Biography.*Please enter your Biography below:*Please provide a link to your online Biography:* Presentation Title*Please confirm the date of your upcoming presentation:* Date Format: MM slash DD slash YYYY Presentation DescriptionProvide a copy of your presentation.*I will upload a copy of my written materials belowI will email my written materials in advance of the meeting (e.g., PDF, MS Word, PPT, etc.)I will bring written materials to the meetingI will not use a PowerPoint or provide written materialsYou may also email your presentation to email@example.com. If you are not able to send the presentation early, please bring it to the conference with you on a USB thumb drive or CD/DVD. We need to load your presentation on our computer for testing no later than 8 a.m. on the day you are to speak.PLEASE ENSURE YOUR PRESENTATION IS SUBMITTED ON THE LTAMS POWERPOINT TEMPLATE.Presentation File Drop files here or Please attach your presentation to ensure it will run properly and load it onto the computer at the facility.Please indicate which audiovisual equipment you will need to give your presentation. Check all that apply. Projector PowerPoint Flipchart with Markers Lavalier Microphone Microphone on Stand Podium Internet DVD PlayerLet us know if you have other A/V needs not listed above. LTAMS recognizes that your time and contributions are vital to our organization’s success and we highly value the leaders who help us advance the land title industry in Mississippi. LTAMS is generally unable to pay speaking fees and/or provide full travel reimbursement and full conference complimentary registrations to all speakers. If a speaker can provide for their own travel expenses, they are encouraged to do so as supportive proponents of the association. However, with prior written approval and only to the extent that funds and/or benefits are available from a third-party sponsor or from excess funds or donated services generated by this event, LTAMS may be able to provide limited supplemental travel support to help encourage participation in advancing the organization’s mission around intellectual exchange, career development, and community building. Those who are unable to fully cover their own travel expenses may request limited travel expense reimbursement for consideration in advance of the event.Do you require any travel expense reimbursement?*YesNoAt which type of event have you been requested to speak?*Select OneAnnual Conference (2-day Event)Seminar (1-day Event)Regional Lunch 'n Learn (1-hour)Live Webinar / Teleconference (1-hour)On Demand Webinar (1-hour)Which of the following travel expenses would you like to request assistance with?* Roundtrip airfare (at the lowest coach rate available and not to exceed, US $750) Mileage (at the rate of US $0.50 per mile) Complimentary program or event registration for the day of your presentation only (excluding sessions or events that may require an additional fee) One night of hotel accomodations (for the night prior to your presentation; not to exceed the $150 per night)Additional Information: Phone calls, video rental, parking fees, taxi, and transportation to and from the airport, unless otherwise noted, are not reimbursable. If you require a speaking fee or reimbursement for travel expenses not addressed above, you must obtain prior written approval.Which of the following travel expenses would you like to request assistance with?* Mileage (at the rate of US $0.50 per mile) Complimentary program or event registration for the day of your presentation only (excluding sessions or events that may require an additional fee)Additional Information: Phone calls, video rental, parking fees, taxi, and transportation to and from the airport, unless otherwise noted, are not reimbursable. If you require a speaking fee or reimbursement for travel expenses not addressed above, you must obtain prior written approval.There is no expense reimbursement available for the event you've been requested to speak at. Please let us know if there is anything that we should be aware of in connection with your presentation that was not covered above:NOTE: If you do not want your presentation to be made available as an on-demand course via the LTAMS online learning management system, please let us know here.Acceptance of Terms* I acknowledge that I have read the Speaker Copyright Release and agree to be bound by its terms. I affirm that entering my phone number below and submitting this form constitutes my electronic signature of this form. I request that my presentation not be recorded and not be made available as an OnDemand webinar course.Phone*PhoneThis field is for validation purposes and should be left unchanged.