GHC 17 Speaker Information Share This Facebook Twitter Googleplus LinkedIn Mail Thank you for participating in this year's Grace Hopper Celebration (GHC). We look forward to hearing you speak! Please provide us with the following information. Step 1 of 3 33% Please select what type of speaker you are.*KeynoteProfessional developmentFeatured speakerABIE Award winnerOtherPlease specify.*Name* First Last Phonetic spelling of your name First Last Preferred professional titlePlease let us know how would you like to be introduced on our website and onstage preceding your award presentation.Preferred email address*Please enter the email address you wish us to use to contact you. If you have a point of contact, you will have the opportunity to add that person's information later on in this form. Cell phone*For use at GHC if we need to contact youPhotographs (for our GHC website and program)*Accepted file types: jpeg, jpg.Please provide three to five high resolution photographs (300 dpi minimum in a jpeg format).Photograph 2*Accepted file types: jpg, jpeg.Photograph 3*Accepted file types: jpg, jpeg.Photograph 4Accepted file types: jpg, jpeg.Photograph 5Accepted file types: jpg, jpeg.Introduction*Please write a 150-word introduction of yourself here. This will be read when you are introduced on stage.Are you attending any other GHC sessions?*YesNoPlease select which session(s) you are attending.* Private reception TEF Senior Women's Symposium Board meeting Speaker's Corner Other Session title* Twitter handleFacebook profile LinkedIn profile Website Are you the main point of contact for pre-GHC matters and concerns?*YesNoPrimary point of contact* First Last Please provide the following information about your point of contact.Primary point of contact's email* Primary point of contact's phone*Do you have a secondary point of contact?*YesNoSecondary point of contact* First Last Secondary point of contact's email* Secondary point of contact's phone*Please provide the name of your assistant.* First Last Assistant's email* Assistant's phone*Will you be the onsite point of contact?*YesNoPlease provide the name of the onsite point of contact.* First Last Onsite point of contact's email* Onsite point of contact's phone* Are you bringing any additional guests or staff?*YesNoName of guest or staff* First Last Guest's or staff's title/roleName of second guest or staff First Last Second guest's or staff's title/roleDo you require any VIP reserved seating for the Main Stage Keynote?*Please note that VIP seating is just for sectioned seats during the keynote presentation, and that those sitting must be registered already for GHC.YesNoHow many VIP reserved seats do you need? Choose up to four.*Please enter a value less than or equal to 4.Flight arrival date Please be sure to arrive at least one day in advance for the Keynote rehearsal.Flight arrival time : HH MM AM PM Flight airlinesFlight numberAre you reserving a room through the Anita Borg Institute hotel block?*YesNoWe partner with the closest hotels to receive discount rates for our speakers. It may be more cost effective for you to book through our hotel block.Confirmation numberHotel nameHotel check-in datePlease note the conference is October 4-6. Hotel check-in date Please note the conference is October 4-6. You are required to arrive the morning before you are scheduled to receive your award in order to complete rehearsal. We will cover hotel accommodations for up to 4 nights. You are welcome to book extra nights that will be charged to you.Hotel check-out date Your home address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country For tax purposesPlease upload your W-9 form here.If you are an international award winner, please upload your wire transfer form here.As an ABIE Award winner, the Anita Borg Institute will cover the registration fee for one additional guest. Will a guest be accompanying you to GHC?*YesNoName of guest* First Last Guest's organization*Guest's email* Additional questions or commentsPlease let us know if you have any questions or need any special accommodations such ADA requirements.