Event Registration Form

Event Registration Form

Please use this form to register all events and seminars. This includes Formal and Informal events. For help call: (800) 420-9767. If you are registering more than one event, you can use the Bulk Uploader below to send us the approved Spreadsheet.
BULK UPLOADER. Use this tab to upload the approved Spreadsheet with multiple seminar dates:

Browse Files

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Note: If you use the Bulk Uploader above with multiple seminars or events, you do NOT need to complete the info the rest of you info below.
GlobalhealthUnitedhealthcareHumanaBlue CrossAetnaChristusImperialCommunityCareWellcareOther
HMOPFFSPPOUnder-65 HealthSupps only (No MAPD)C-SNPD-SNP
20252026
Contract Number (leave blank)
EnglishSpanishOther
Formal Sales Seminar (specific product)Educational SeminarInformal Sales Event (set up a table at an event)Formal Sales Presentation (not product specific but general info)
Public (anyone can attend)Private (only open to members of this organization).
Event Name (Name of Venue)
Event Date

MonthDayYear
Event Start Time

:HourMinutesAM/PM Option
MedicarePrepare
Fitness CenterChurchRetirement CenterSenior ApartmentOther
Facility (if other)
Representative NPN #
Representative / Agent Name
Venue Name
Venue Phone #
Venue Address
Venue Address 2
Venue City
Venue State
Venue Zip Code
Event Contact (Agent)
Contact Phone Number (Agent)

Area CodePhone Number
Presenter 1 (Agent)
Presenter 2 (Agent)
How will you market this?
Any notes, questions or comments?
YesNo
Should be Empty: