"*" indicates required fields Step 1 of 3 33% 2023 International Conference & Induction of Fellows RegistrationPlease select one of the following types of registration:*Fellow/Associate Fellow Registration $1,995Speaker Registration $1,295Panel Registration $1,595Non-Fellow Registration $2,295Corporate Diversity Partner/Sponsor RegistrationThe CLSA conference registration fee is fully refundable for cancellations received on or before Friday, September 1, 2023. Cancellations received between September 2 and October 2, 2023, will be refunded at fifty percent (50%) of the total fee, OR the total fee may be credited to a future CLSA event. Due to the financial commitments made to the Resort by the CLSA, cancellations received on or after Tuesday, October 3, 2023, are non-refundable. I have read and agree to the terms and conditions of the above Cancellation Policies.*I agree.I do not agree. Fellow/Associate Fellow Registration Speaker Registration (Individual) Panel Speaker Registration Non-Fellow Registration Corporate Diversity Partner Registration Name* Dr.MissMr.Mrs.Ms.Hon.Prof.Rev. Prefix First Middle Last Suffix Name as you would like it to appear on your badge (ex. Steve instead of Steven):* Guest of:* Firm or Company Name:* Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone:*Cell Phone Number: Cell phone to be used only by CLSA staff in the event we need to contact you during the conference. Not to be published or distributed elsewhere.Email:* Please indicate for which state(s) you are seeking CLE Credit and provide corresponding Bar/License Number(s):*State(s) in which you are licensed:Bar/License Number(s): Add Remove*If licensed in more than one state, please select the round button above to add additional rows. Please list all allergies and/or dietary restrictions:* Have you already been formally inducted at a previous CLSA gala?*YesNoWill you be bringing a guest to the social events?*YesNo Registered guests are invited to attend the Welcome Reception on Wednesday, November 1st and the Induction of Fellows Gala on Thursday, November 2nd. Guest Registration Fee: $395 per guest Fellow/Associate Fellow Conference Registration Fee:* Price: Speaker Conference Registration Fee:* Price: Panelist Conference Registration Fee:* Price: Non-Fellow Conference Registration Fee:* Price: Guest Registration:Number of Guests:*1 Guest + Fellow/Associate Fellow Registration2 Guests + Fellow/Associate Fellow RegistrationNumber of Guests:*1 Guest + Speaker Registration2 Guests + Speaker RegistrationNumber of Guests:*1 Guest + Panelist Registration2 Guests + Panelist RegistrationNumber of Guests:*1 Guest + Non-Fellow Registration2 Guests + Non-Fellow RegistrationNumber of Guests:*1 Guest2 GuestsGuest's Name: Dr.MissMr.Mrs.Ms.Hon.Prof.Rev. Prefix First Last Please list all allergies or dietary restrictions of your guest: Guest #2:Guest #2 Name: Dr.MissMr.Mrs.Ms.Hon.Prof.Rev. Prefix First Last Please list all allergies or dietary restrictions of your guest: CAPTCHA Thank you for registering for the 2023 International Conference & Induction of Fellows. Your total is: Thank you for registering for the 2023 International Conference & Induction of Fellows. Your total is: Thank you for registering for the 2023 International Conference & Induction of Fellows. Your total is: Thank you for registering for the 2023 International Conference & Induction of Fellows. Your total is: Thank you for registering for the 2023 International Conference & Induction of Fellows. Your total is: Thank you for registering for the 2023 International Conference & Induction of Fellows. Your total is: Thank you for registering for the 2023 International Conference & Induction of Fellows. Your total is: Thank you for registering for the 2023 International Conference & Induction of Fellows. 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