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* 1. First Name

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* 2. Last Name

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* 3. Credentials

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* 4. Current Title

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* 5. Current Organization

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* 6. Work Email

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* 7. Personal Email

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* 8. Work Phone

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* 9. Mobile Phone

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* 10. Bio

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* 11. LinkedIn Profile

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* 12. What topic or topics are you qualified and interested in speaking about?  Please be as specific as possible (e.g., not “contracts”)

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* 13. By submitting this form you are confirming that:

1 - You would be available and willing to travel to Philadelphia for the WCG MAGI conference, if you are speaking
2 - You are or will be fully-vaccinated against COVID-19 (required for all attendees)

I understand (Type Name to Agree)

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