2022 IPLI Information Request Name* Position* Company* Phone* Email* Do you have any dietary restrictions or do you require any special accommodations? If so, please provide details.__________________________BIO AND PROFESSIONAL HEADSHOT(Your bio and headshot will be published in the IPLI2022 booklet. Please proofread before submitting this form.) Bio (max 750 characters)* Professional Headshot (min 300 dpi, jpg/jpeg files only)*__________________________REQUIRED AGREEMENTSHNBA/VIA IPLI2022 Individual Release Indiv Release*I confirm that I have read, understand, and agree to the above HNBA/VIA IPLI2022 Individual Release linked above.HNBA/VIA Code of Conduct Code of Conduct*I confirm that I have read, understand, and agree to the above HNBA/VIA Code of Conduct linked above.__________________________COVID-19 PARTICIPATION POLICYHNBA/VIA IPLI2022 COVID-19 Participation Policy COVID*I confirm that I have read, understand, and agree to the above HNBA/VIA IPLI2022 COVID-19 Participation Policy linked above.I will not be attending in-person.PROOF OF VACCINATION VaccineCard*I hereby agree to the HNBA/VIA’s COVID Vaccine Policy and will present my vaccine card OR a clear and legible photo of the vaccine card as proof that I have been fully vaccinated against COVID and received at least one booster shot. I understand that I will be unable to participate if I do not comply with this policy.I will not be attending in-person. Addition CaptchaSubmitReset
