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342 North Main Street, West Hartford, CT 06117
860/586-7561, Fax 860/586-7550
Speaker Agreement Form: 2008 Annual ACUA Conference
September 14 - 18, 2008
General Speaker Information
Speaker
Name Speaker Title
Company
Name
Address
City/State
/Zip
Daytime Phone Cell Phone
Fax
E-mail Address (required):
Please indicate any dietary, medical or physical
challenge requirements:
If a paid speaker - provide speaker’s tax-ID number or social security number if an honorarium is involved. Can
also call ACUA at 1-806-586-7561 ext. 2 to provide this information
(Must have before payment) ___________________________________________________________
Indicate One: ACUA Member: Non-Member:
General Session Information
Session Title (exactly as it is to be printed on all promotional material):
Workshop Date: Time: Session #: Advance Preparation: Yes No
Session Program Level (select one): Advanced Intermediate Basic Overview Update
Program Prerequisites: Education Experience Both None
If a double session, is the first session a prerequisite? Yes No
Field of Study
(Track Coordinator please verify selection based on NASBA “CPE Fields of Study”)
Accounting Business Management & Organization
Governmental Accounting Finance
Auditing Management Advisory Services
Governmental Auditing Marketing
Administrative Practice Behavioral Ethics
Social Environment of Business Communications
Regulatory Ethics Personal Development
Business Law Personnel/HR
Mathematics Production
Specialized Knowledge & Applications Statistics
Taxes Computer Science
Economics
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Program Content and Learning Objectives
Include a description of the program content. Must include specific learning objectives, preferably in
bulleted format. Content is limited to 150 words Complete the box below with no more than 18 lines of
text. This description will appear in the brochure and must be grammatically correct.
Speaker Biography
Must be in paragraph format and be limited to 150 words. Complete the box below with no more than 18
lines of text.
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Audio Visual Requirements
Check all that apply. SPEAKER PLEASE PROVIDE YOUR OWN LAPTOP
S-VGA-Data Projector /Screen Table top lectern microphone
Lapel Microphone Overhead Projector
Flipchart/Easel/Markers 35mm Slide Projector
VCR/Monitor Blackboard
Other (please specify)
Handouts
Please Indicate: I do I do not grant permission to ACUA to include my handouts on the website
that will be provided only to conference registrants after the annual conference.
Handouts – Speaker will:
Provide handouts at the conference
Mail master to ACUA office for copying (Originals due by August 15th)
Ms. Carol Ewing, ACUA
342 N. Main Street
Hartford, CT 06117
Phone: (860) 586-7561
Fax: (860) 586-7550
Have no Handouts
E-mail an electronic format of the handouts to cewing@acua.org for copying (preferred)
Audeo Taping
Permission for Session Taping (optional - not required):
As part of our continuing commitment to provide ACUA members with affordable training opportunities via
the use of audio-taped training sessions made available on the web, please indicate your agreement to
be taped, and if selected, for your taped session to be shown on the web to all ACUA members.
By checking the following box, I agree for my session to be taped and broadcasted on the web to ACUA
members. I agree to provide materials presented during my session electronically to ACUA.
I agree to have my session audio taped.
No, I would not like my session to be audio taped.
Room Setup
Rooms will be set up as classroom style unless another choice is selected. Please note that number of
attendees registered may change room set up preferences.
Classroom style
Hollow Square
U-Shaped
Rounds
Other – please specify:
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Expense Estimate Information
Type of Expense Amount
Honorarium
Registration Fee Waiver
Lodging (See Helpful Tips Below)
Number of nights to be paid by ACUA
Arrival Date
Departure Date
Airfare (See Helpful Tips Below)
Taxi/Shuttle
Mileage (Number of miles x approved ACUA
rate – to be determined)
Parking
Meals
Miscellaneous
(To get Total to appear, Right click the total Total $ 0.00
box and choose Update Field.) Estimated
Expense
Note that the above are estimated expenses.
Helpful Tips for Speakers
Hotel
While ACUA makes arrangements with the hotel to set aside specified room nights for each
speaker, the speaker is responsible for making their own reservation. The hotel this year is the
Hyatt Regency Phoenix; 122 North Second Street; Phoenix, Arizona, USA 85004. Their website is at:
http://phoenix.hyatt.com/hyatt/hotels/index.jsp . ACUA will pay the hotel directly for the agreed upon
nights, but you, the speaker, must call the hotel directly. Please call for hotel booking at (602) 252-1234
and state that you are with the ACUA Conference.
Airline
Reimbursements to airfare will only be made for coach or the most reasonable fare available. When it is
time to purchase your airline ticket, any actual quoted airfare amount that exceeds the estimate indicated
above, by more than $125, should be immediately reported to your Track Coordinator for authorization
before the ticket purchase occurs. An airfare amount that exceeds the original estimate, without obtaining
prior approval from your Track Coordinator, may be subject to reimbursement only up to the original
amount estimated. **Note: The speaker is responsible for making their own airline reservations.
Airline Reservation Guidelines
If ACUA is paying for your air travel, special restrictions and requirements apply:
1. Airline tickets must be purchased through Thomas Travel (ACUA’s official travel agent). Please
call Thomas Travel at (800) 666-3600. Thomas Travel will have a list of all authorized ACUA
speakers. Inform the agent that you are a speaker with ACUA.
2. Airline tickets must be purchased a minimum of 21 days in advance of the travel date. Booking
60 days out gets an extra 5% discount on Delta and Southwest. Keep in mind that the ticket is
NON-REFUNDABLE.
3. Seat selection is limited to Coach Class and no modifications to the ticket are allowed.
4. Thomas Travel will make the best possible arrangement for your air travel.
5. Prior to booking the airline reservation, Thomas Travel will notify the ACUA Executive office for
authorization.
6. Thomas Travel will direct bill ACUA for the airline ticket in order to avoid speaker out-of-pocket
expenses.
7. Confirmation will be sent from Thomas Travel once the reservation has been processed.
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Other Information
After the conference, ACUA would like to send a letter of gratitude to each of the speakers. ACUA is
more than willing to send a copy of this letter to the speaker’s supervisor or some other person of choice.
Please indicate who the speaker would like a copy of the letter sent to:
Name:
Title:
Address:
City/State/Zip:
Approvals
Track Coordinator Date
Conference Director Date
Please type name and date above.
NOTE: This speaker agreement form will only be valid once the Conference Director has agreed to this
document.
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