Presenter Information

Name as it appears on tax forms (for reimbursement and honorarium purposes). Note: LAVIS plenary speakers and LAVIS advisors are eligible for travel reimbursement. LAVIS presenters from overseas are eligible for partial travel reimbursement. You must have receipts to receive any reimbursements. LAVIS presenters will receive a small honorarium. You must attend the conference to receive your honorarium.

____________________________________________________________________________________________

Social Security Number (for reimbursement and honorarium purposes): _________-_______-____________
(Note: If you do not have a social security number, contact Mike at picone@ua.edu or Catherine at cdavies@bama.ua.edu)

Affiliation: __________________________________________________________________________________

Mailing Address: _____________________________________________________________________________

____________________________________________________________________________________________

Phone Number: _________________ E-mail Address: ______________________________________________

Mail your completed form to
University of Alabama
Box 870246
LAVIS III/ Attention: Mike Picone
Tuscaloosa, Alabama 35487-0246 USA

Please remember that presentations have a 20-minute time limit. If you are using handouts, please bring at least 35 copies and leave one at the registration desk. You will be given multi-media needs check-in information when you arrive at the conference.

_____ None

_____ TV/VCR

_____ Cassette player

_____Plain paper projector (ELMO)

 

A selection of LAVIS III presentations may be videotaped for inclusion as streaming-video components of the post-conference phase of the LAVIS website.

I, ___________________________________, _____grant/ _____do not grant my permission for my LAVIS III presentation to be video-recorded and for this recording to be made available through the LAVIS website.