GW Operational Medicine Event Intake Information Form

Full Name of Event

Location of Event

Event at Washington Convention Center

Location at Washington Convention Center:

Event Dates & Times

Estimated Attendance of Event

Alcohol served?

Number/Type of Providers Needed:

Email Address

Confirm Email Address

Phone Number

Client Registration Form

Primary Contact Information

Business Name

Contact Person

Street Name

Street Address Line 2

City

State

Zip Code

Email Address

Phone Number

Client/Account Information

All information is same as above

Business Name (Full Legal Name)

Contact Person

Street Name

Street Address Line 2

City

State

Zip Code

Email Address (To Receive Contract)

Phone Number

Invoicing Information

(Invoices will be sent within 30 days following end of event)

All information is same as above

Business Name

Contact Person

Street Name

Street Address Line 2

City

State

Zip Code

Email Address* (To Receive Invoice)

Confirm Email Address

Confirm email

Phone Number

Request for MFA Certificate of Insurance (Optional)

Certificate Holder Name:

Name of Additional Insured*

Relationship to person above:

Name of Additional Insured*

Relationship to person above:

Name of Additional Insured*

Relationship to person above:

*MFA will only add Client as an additional insured on MFA's professional liability insurance policy.

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