2015 Presidents' Forum Registration Form

12TH Annual Meeting of the Presidents’ Forum “Unshackling Innovation: Regulation vs. Innovation” Hosted by The Presidents’ Forum and United States Distance Learning Association November 18, 2015 (Wednesday) 8:00 a.m. – 4:00 p.m. U.S. Chamber of Commerce | Hall of Flags 1615 H Street, NW, Washington, D.C. 20062 Registration Form Attendee Information: First Name:*_____________________________________________________________________________ Last Name:* _____________________________________________________________________________ Organization: ___________________________________________________________________________ Title: __________________________________________________________________________________ Department: ____________________________________________________________________________ Your Name Tag Text: _____________________________________________________________________ Telephone:* _____________________________________________________________________________ Facsimile: ______________________________________________________________________________ Email Address:* __________________________________________________________________________ Any Special Needs (?): ____________________________________________________________________ Attendee Address: Address Line 1:*__________________________________________________________________________ Address Line 2: __________________________________________________________________________ City:*___________________________________________________________________________________ State:* _________________________________________________________________________________ Zip Code:* ______________________________________________________________________________ Registration: $450.00 Registration Fee Payment Method:* Invoice: _____ Check: _____ Made payable to: USDLA | Mail to: Trish Marcelonis, USDLA, 76 Canal Street, Ste. 301, Boston, MA 02114 Credit Card: _____ Call Trish Marcelonis at (617) 339-1770 * = Required Field

Complete and submit form to Trish Marcelonis at [email protected] or fax to (617) 399-1771 Questions: Contact Trish Marcelonis at (617) 399-1770 or [email protected]

Cancellation and Refund Policy: Cancellations must be received prior to September 1, 2015 in order to receive a conference refund (less a $75.00 processing fee per registration). All refunds will be processed after November 30, 2015. Cancellations after September 1, 2015 will not be refunded; however, a substitute may attend for the registered attendee at no additional charge. Hotel Information: Participants should make their own hotel reservations. A limited block of rooms at a rate of $299.00 are reserved at the Mayflower Renaissance Washington, DC Hotel through Sunday, October 16, 2015. Contact the Mayflower Renaissance Washington, DC Hotel directly and reference the group name "Excelsior Presidents’ Forum" to reserve a room at this reduced rate. The Mayflower Renaissance Washington, DC Hotel 1127 Connecticut Ave NW Washington, DC 20036 Reservations Toll Free: (877) 212-5752 Reservations Local Phone: (202) 347-3000 Reservations Online: https://resweb.passkey.com/Resweb.do?mode=welcome_ei_new&eventID=13905309 You may also visit https://www.uschamber.com/hotels-near-us-chamber-commerce for a listing of nearby hotels. Event Information: Welcome Reception | November 17, 2015 |6:00 p.m. - 8:00 p.m. The Mayflower Renaissance Washington, DC Hotel Promenade Ballroom 1127 Connecticut Avenue NW, Washington, D.C. 20036 12th Annual Meeting |November 18, 2015 |8:00 a.m. - 4:00 p.m. U.S. Chamber of Commerce Hall of Flags 1615 H Street NW, Washington, D.C. 20062 Event Contacts: Paul Shiffman | (518) 464-8803 | [email protected] Sharon Zullo | (518) 608-8162 | [email protected] Sponsor Contacts: Paul Shiffman | (518) 464-8803 | [email protected] Patricia Marcelonis | (617) 399-1770 | [email protected]

The Presidents’ Forum |7 Columbia Circle | Albany, NY 12203 USDLA | 76 Canal Street | Suite 301| Boston, MA 02114