WKU CPD

All questions marked by an asterisk are required

Event Name:

2023 Kentucky Convergence Conference - Attendee

*First Name:

*Last Name:

Prefix:

*Email Address:

*Retype Email Address:

*Address:

*City:

*State/Province/Region:

*Zip/Postal Code:

*Phone Number:

{xxx-xxx-xxxx}

*Employer/Organization:

*Position Title:

If you selected 'other' please tell us your position title:

*Would you allow your email to be shared with our KY Convergence Conference Sponsors?

Yes
No

How would you like your name to appear on your name tag (if different from above)?

Do you have any dietary restrictions? Example: Vegan, Vegetarian, Gluten Free, etc. *We will do our best to accommodate.:

Discount Code: