PSA Live 2015 Speaker Information Please complete the information below regarding your speaking at PSA Live 2015. Speakers at LIVE 2015 Form to be sent to LIVE 2015 Speakers Name* First Last Email* Is this your first time at a PSA convention?*YesNoMembership Level*Please Select OneAssociate MemberProfessional MemberFellowNon MemberInternational GuestCSPPlease detail if you are a member of any other professional speaking associations in the UK or internationally.Address* Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Dietary RequirementsPlease let us know if you have any dietary requirementsI have a dietary requirement*YesNoPlease select your dietary requirement*VegetarianVeganHalalKosherNo PorkAllergyAllergy*GlutenNutWheatLactose IntolerantPlease detail your contact telephone number (including the country code if applicable)*Please detail a contact number for yourself on the day of the convention (including the country code if applicable)*Please state an individual that we should contact in case of an emergency. Please provide details of their name, their relationship to you, and a contact number.*What is your speaking/ presenting role at PSA LIVE 2015*MCMain Platform SpeakerMeet the Pro'sWhat is the title of your presentation?*Do you have any AV requirements (Slides/Type of Microphone/flip chart etc)*Do you have any props - if so please detailAs a Speaker/Presenter involved in PSA LIVE 2015 I understand that: I must register and pay to attend the convention (unless you are a international speaker) I must provide, produce and distribute my own handouts I must refrain from mentioning, selling, or promoting any products or services unless I have permission from the Convention Chair I will honour and agree to the PSA Code of Ethics, this can be viewed at http://www.thepsa.co.uk/membership/ethics/ I authorise the PSA to electronically record, in any form, my presentation I authorise the PSA to market, sell and promote my presentation in any form to PSA members and International Federation Members and Non Members I understand that my presentation may be filmed and featured in marketing materials used by the PSA I understand that I must obtain written permission by the music publisher and recording label if I am using pre-recorded music in my presentation, and that this must be provided to the conference chair 2 weeks prior to the event I understand that I must get expressed or written permission to use intellectual property such as photographs, videos, cartoons, articles etc Do you have any disabilities we need to consider?*YesNoDisability*Wheelchair userVisually impairedPhoneThis field is for validation purposes and should be left unchanged.