Speaker Data Form - The Institute of Internal Auditors

IIA Logo & Name Blue Small

2012 Revolutionizing Internal Audit Conference

The Boston Convention and Exhibition Center,

July 8 - 11, 2012

Boston, MA

Please utilize this template for your presentation slides. To Add Your Logo to the Slide Master, open the View tab on the Ribbon and then click the Slide Master button, found in the Presentation Views Group. The Slide Master opens displaying placeholders for the slide title and body text and a spot titled, “Insert Logo Here.” A thumbnail of each Slide Master as well as the layouts for each Master Slide are shown on the left side of the screen.

(* Required)
PERSONAL DATA
FULL NAME: *
BADGE NAME: *
PROFESSIONAL TITLE:
PROFESSIONAL IIA DESIGNATIONS:
EMAIL: *
COMPANY: *
ADDRESS: *
ADDRESS 2:
CITY:
STATE/PROVINCE:
ZIP/POSTAL CODE: *
COUNTRY: *
PHONE: *
FAX:
MOBILE:
IIA Member *	Yes
	No
IIA MEMBER ID (If Applicable)
*ASSISTANT CONTACT INFORMATION:*
NAME:
EMAIL:
PHONE:

SESSION DATA
SESSION TITLE:
SESSION DATE (MM / DD / YY)
(Session Start time and End time Example: If you arrive at 11 in the morning and depart at 2 in the afternoon then enter Start time: 11:00AM End time 02:00PM.)
SESSION START TIME (_ _:_ _)
SESSION END TIME (_ _:_ _)
LEARNING LEVEL FOR ATTENDEES SESSION 1
(Please select Only One field)
FIELD OF STUDY FOR SESSION TITLE 1:

SECOND SESSION TITLE: (if applicable)
SESSION DATE (MM / DD / YY)
(Session Start time and End time Example: If you arrive at 11 in the morning and depart at 2 in the afternoon then enter Start time: 11:00AM End time 02:00PM.)
SESSION START TIME: (_ _:_ _)
SESSION END TIME (_ _:_ _)
LEARNING LEVEL FOR ATTENDEES SESSION 2
(Please select Only One field:)
FIELD OF STUDY FOR SESSION TITLE 2:

PLEASE INDICATE:
I grant permission to The IIA to include my presentation (slides) on the Web site that will be provided only to conference registrants prior to and after the conference.

I desire to interact with media interested in covering my session or interviewing me for a news story related to my field of expertise.

I desire to participate in social media facets for this event of The IIA.

I grant permission to The IIA to audio/video tape my session and inculde slides for other events.


*Presentations-Speaker will:*
	Provide presentation by scheduled due date of June 3, 2012 to international.conference@theiia.org
	Have no presentation
	I further agree to comply with all program-related deadlines provided to me by The IIA, including but not limited to deadlines for submission of biographical data, presentation tiles, presentation descriptions (abstracts), A/V request, travel schedules, and etc.
	During my presentation I will not engage in any product or service and I will refrain from making any comment that may negatively impact the brand or reputation of The Institue of Internal Auditors in any way.
	I agree to notify The IIA's International Conference Manager, Kristi Coombs immediately in the event that an emergency should prevent me from meeting my obligation as a speaker or presenter.
	I grant to The IIA a royalty-free unlimited license to use, reproduce and distribute my presentation in any way in perpetuity, provided that appropriate attribution is given to me. I understand that this license does not change the fact that I retain copyright ownership of my presentation, and does not prohibit me from using my presentation in any way or from allowing others to use it.
	I agree to use the PowerPoint template and logo provided to me by The IIA for any PowerPoint presentation I may utilize in connection with the program, and I agree not to use these templates and logos in any way except in connection with this or other IIA programs.
	To the best of my knowledge, my presentation does not violate any proprietary or personal rights of others (including any copyright, trademark and privacy rights), is factually accurate, and contains nothing defamatory or otherwise unlawful. I have the full authority to enter into this agreement and have obtained all necessary permissions or licenses from any individuals or organizations whose material may be included or oherwise used in my presentation.
	I authorize The Institue of Internal Auditors to use my name, likeness, photograph, and biographical data in connection with the use and promotion of the program.
I have reviewed the Speaker Agreement above and will support The Institute of Internal Auditors commitment to present the highest quality business conference, with the most current and effective auditing approaches and solutions, to its audience. By my signature (or by typing in my name). I understand and agree to the above.
Speaker:
Date: