First-name:
Last-name:
Degree:
Address1:
Address2:
City: State:
Zipcode:
Phone: ( ) - extn.
E-mail:
Employer:
   
Degree Year Institution (Name, City, State) Area of Study
       
Please type a short biographical sketch in the area below and please include information on your present postion: example
 

Instructions

  • All text fields with a red box beside them are required fields. You will not be able to submit the form without filling out those fields.
  • For your employer, list the organization you want to appear below your name on your name tag. example
  • For the education section, fill out the degrees you have recieved starting with the most recent awarded. Replace the text only on the lines you need. example
  • A short biographical sketch, typed in the third person, is required. example
 
 
 
   
  Will you have handouts that you need us to copy? If so, we need the originals by August 29th.

 

  Class 1
Title:
Purpose:
 
 
Objective 1:
Objective 2:
Objective 3:
  Do you need any of the following A/V equipment for this class? more information
  Slide Pojector: Overhead: Flip Chart:  
  VCR/Monitor: Wireless Mike: LCD Projector:  
  Other:   Contact hours:    

 

  Class 2
Title:
Purpose:
 
 
Objective 1:
Objective 2:
Objective 3:
  Do you need any of the following A/V equipment for this class?
  Slide Pojector: Overhead: Flip Chart:  
  VCR/Monitor: Wireless Mike: LCD Projector:  
  Other:   Contact hours:    

 

  Class 3
Title:
Purpose:
 
 
Objective 1:
Objective 2:
Objective 3:
  Do you need any of the following A/V equipment for this class?
  Slide Pojector: Overhead: Flip Chart:  
  VCR/Monitor: Wireless Mike: LCD Projector:  
  Other:   Contact hours:    

 

  Class 4
Title:
Purpose:
 
 
Objective 1:
Objective 2:
Objective 3:
  Do you need any of the following A/V equipment for this class?
  Slide Pojector: Overhead: Flip Chart:  
  VCR/Monitor: Wireless Mike: LCD Projector:  
  Other:   Contact hours:    
   
I give permission for paticipants to audiotape the seminar(s) in which I am presenting.
 

Please hit the "Submit" button only once.  If you do not get a pop-up window asking if it is ok to submit the form, then go back to the top and make sure you filled out all the required fields.