Proposed title of presentation:

Presenter name and credentials:

Company name:

Job title:

Company website address:

Address:

City:

State:

Select One Georgia Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Vigin Islands Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Africa Armed Forces Americas Armed Forces Canada Armed Forces Europe Armed Forces Middle East Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon International

Zip code:

Phone number:

Cell number:

Email address:

Are you a GHIMA member?

Yes No

Enter a brief description of presentation (50 to 75 words). This will be included in the pre-registration marketing brochure and onsite program materials.

Enter the presenter bio. This is a brief narrative biography for each presenter. It will be used to introduce the presenter(s) at the seminar, and may be included on marketing brochure and onsite materials.

Honorarium and/or other expense reimbursement being requested, if any.

Reimbursement for expenses is not requested. My company will sponsor my presentation (recognition to be in program       marketing materials.) Reimbursement is requested.

If an honorarium and/or other expense reimbursement is being requested, include the description and expense for each item. For example, enter the amount requested for the honorarium, ground travel, coach air travel, lodging, and other.

What are your audio visual or room set-up requirements? (GHIMA does not provide laptops.)

LCD projector and screen (e.g. for PowerPoint) Lavaliere microphone Flip chart Speaker podium or small table Head table (e.g. panel discussion)

Thank you for your interest in speaking during the GHIMA Annual Meeting.  The Program Chair will be in touch with you soon. Disclaimer: GHIMA does not allow presenters, vendors, consultants, panelists, etc. to promote their own products and/or services in any educational sessions. (Panelists may discuss the use of a product or service within the context of their panel discussion for educational purposes.) Vendors are encouraged to use alternate means of advertising such as exhibiting and/or sponsorships.