"Speaker Agreement Form 2006 Annual ACUA Conference"
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 Page 1 of 5 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. Page 2 of 5 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 firstname.lastname@example.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: Page 3 of 5 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. Page 4 of 5 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. Page 5 of 5