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April 26, 2024 5:00 pm

Fairmont Dallas - 1717 N. Akard Street Dallas, TX 75201

Deuruxolitinib Community Dermatology Commercial Advisory Board

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Personal Details

Salutation*

First Name*

Last Name*

Credentials (Enter N/A if Not Applicable)*

Name Preferred for Name Badge*

Specialty

Job Title*

Affiliation/Organization*

Office Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Mobile Phone*

Email*

Admin Email

Emergency Contact*

Emergency Contact Number*

Do you have any dietary restrictions?*

Yes

No

Comments

Hotel Needs

Will you require a hotel room?*

Yes

No

Select check in date*

MM slash DD slash YYYY

Select check out date*

MM slash DD slash YYYY

Number of occupants*

Single occupancy

Double occupancy

Bed preference (based on availability)*

Single king bed

Double queen bed

Comments or additional room preferences:

Travel Needs

Do you need travel arrangements?*

Yes, flight

Yes, train

No

Flight

Information in this section must match exactly with the details that appear on your driver’s license or government issued ID. Please review prior to moving ahead.

Train

Information in this section must match exactly with the details that appear on your driver’s license or government issued ID. Please review prior to moving ahead.

Legal Last Name (Including Suffix)*

Legal First Name*

Legal Middle Name or Initial

Date of Birth*

MM slash DD slash YYYY

Gender*

Leaving From*

Departure Date*

MM slash DD slash YYYY

Arriving To*

Return Date*

MM slash DD slash YYYY

Return Leaving From*

Return Arriving to*

Preferred Seat (Based on Availability)*

Preferred Seat (Based on Availability)*

Preferred Airline 1

Preferred Airline 2

Preferred Railway

Frequent Flyer Number 1

Frequent Flyer Number 2

Rewards Number

Known Traveler Number (TSA)

Redress Number

Will you require ground transportation?*

Yes

No

Will you require inbound ground transportation?*

Yes

No

Will you require outbound ground transportation?*

Yes

No

Comments or additional travel preferences:

Submit Registration

Please submit your information by clicking the "Submit Registration" button. The Sensified logistics team will then process your registration.

You will receive a confirmation email shortly after your submission. If you do not receive a confirmation email, please contact Sensified at 540-798-7115 or mcpennino@sensified.com

DETAILS

Hotel Information
Fairmont Dallas
1717 N. Akard Street
Dallas, TX 75201

Friday, April 26, 2024
Arrivals: Afternoon/early evening
Group Dinner: Time TBD (~6:30 pm)
Group Dinner Location: TBD

Saturday, April 27, 2024
Breakfast: 7:15 – 8:00 am
Meeting AM Session: 8:00 am – 12:00 pm
Lunch: 12:00 – 12:45 pm
Meeting PM Session: 12:45 pm – 3:00 pm
Departures: 3:00 pm

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