2021 NDSEG CLASS CONFERENCE

Speaker Reg Form

Speaker Registration Form

Please select all that applies

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Title/Rank (Mr., Mrs., Dr., CPT, LTC, CAPT, CDR, MAJ, GEN, ADM, LtCOL, etc)

First Name

Last Name

Job Title

Organization / Institution Name

Password

Mailing Address

Address 1

Address 2

City

State

ZIP

Emergency Contact: Name

Emergency Contact: Phone Number

Affiliation

DoD Agency

Phone Number (Please provide a number that you can be reached during the conference)

Are you a Former Fellow?

Primary Research Discipline Area

Other Research Discipline Area

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Select the days that you are attending:

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Would you be interested in serving as a DoD Mentor for upcoming NDSEG Class? (About Mentor Program (ndseg https://ndseg.org/about-mentor-program.org))

Would you be willing to serve as a Subject-Expert Reviewer for the NDSEG Application? (About Subject-Matter-Experts https://ndseg.org/smes)

ADA Accessibility Requirement. If you are a qualified individual with a disability or a disabled veteran, do you require reasonable accommodation during the conference?

Would you be interested in the opportunity to be an evaluator for posters and technical presentations?

Acknowledgement/Photo and video-taking

I acknowledge that Photos and videos may be taken during the conference for education and learning purposes. While the DoD is not required to get permission from attendees, we would like every attendee to be aware that images and videos may be captured. By registering for the NDSEG conference, you acknowledge that photos and video may be taken. Contact ndseg@its-jv.com should you have any questions or concerns

Dietary Restrictions/Meal Preference

Please let us know your dietary restrictions (if any) or meal preference by answering the questions below.

STRICT DIETARY REQUIREMENT | If applicable, please select your strict dietary requirement from the list below:

FOOD ALLERGY | I have the following Food allergy (please select all that apply):

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Follow-ups:

You will receive a link to the Hotel for Room Reservations and Travel guidelines immediately upon registration. Please check you spam or junk folder if you do not receive the link within 20 minutes. You can also reach out to us at ndseg@its-jv.com.

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