2024 National Lifeline & ACP Conference (Funding Members)

First Name: *

Last Name: *

Email: *

Phone Number: *

Can we send you occasional updates related to your registration via text message?: * Yes No

What company do you represent?: *

What best describes your role in the industry?: * ACP/Lifeline Advocate Device Supplier Distributor ETC/ACP Provider Field Enrollment Rep Government Representative Pick-Pack-Ship Supplier Public Interest Group Solution Supplier

Which events are you interested in attending?: Kick-Off Party: Tuesday - October 15 National Agent Coalition (NAC) Meeting: Tuesday - October 15 Sponsored Happy Hour: Wednesday - October 16

Are you staying at the host hotel? (Astor Crowne Plaza): * Yes No Not Sure

Are you interested in speaking at the event, participating in a panel discussion, or moderating a panel? Don't worry, we will contact you to discuss your level of comfort and preferred topics.: * Yes No Maybe

Do we have your permission to give your contact information, including phone number, to event sponsors?: * Yes No

Are you interested in becoming a 2024 conference sponsor?: * Yes No

Is there anything we can do to make this conference more accessible for you? (for example: level access, hearing loop, ramps, seating closer to screens/displays, or anything else): * Yes No

If yes, please provide details of how we can accommodate you:

Do you have any food allergies or restrictions?: * Yes No

If yes, please provide details of dietary restrictions:

How many NaLA conferences have you attended?: * This is my first 1 2 3 4 5 6 7 8 or more

Are you participating in any programs that fund NaLA outside of the Conference?: * Yes No Not Sure

Do we have your permission to include your provided email and phone number to the QR code on your name badge?: * Yes No