MDRT Speaker Submission Form for 2013 ConneXion Zone

* this is a required field

The ConneXion Zone is THE place to go to interact with exhibitors, experience hands-on learning using the latest tools, and share useful business information with your fellow MDRT members. Please fill out the information below about the MEMBER SPEAKER you are recommending to share knowledge and information with MDRT peers in the ConneXion Zone at the 2013 MDRT Annual meeting in Philadelphia. The recommendation form must be submitted by NOVEMBER 16, 2012.

1.How do you know of this speaker?

Self

Heard the speaker present at a meeting, function or other event

Recommended by a colleague

Other (please specify)

2.Name and contact information of the recommended MEMBER SPEAKER (*required fields: first name, last/family name, e-mail, and phone):

*Last/Family Name

*First Name

Designations

Company

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

MDRT Member ID

*Email

*Phone

Fax

Website

3.Please list YOUR contact information whether you are recommending yourself or someone else (*all fields are required):

*Last/Family Name

*First Name

*E-mail

*MDRT Member ID

4.The content of this presentation will appeal to:

Primarily U.S.-based audience

Global Audience

Other (please specify)

5.Will the session be presented in a language other than English?

Yes

If yes, please specify language

6.How long would the presentation be?

15 minutes

25 minutes

45 minutes

Comment

7.What is the title of the presentation?

8.Provide a description of the presentation that would be given. Be as specific as possible.

*9.Speaker's background and credentials for presenting this material:(Required.)

10.If available, please provide a LINK to an online video presentation from this speaker:

Thank you for taking the time to submit this CONNEXION ZONE speaker recommendation. If you have ideas for additional TOPICS to be presented in the CONNEXION ZONE, please fill out the MDRT Topic Submission Form for the 2013 ConneXion Zone on the MDRT website. Million Dollar Round Table 325 W. Touhy Ave. Park Ridge, IL 60068 +1 847.692.6378 www.mdrt.org

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