Please complete this form for each workshop presenter.
Workshops with multiple presenters must submit one form for each
presenter.
Main Contact Person:
Workshop Title:
Presenter’s Name:
Title/Position:
Institution:
E-mail:
Email: (type again to
confirm:
Address:
City/State/Zip:
Telephone:
Fax:
List information which qualifies you to conduct this workshop:
EDUCATIONAL EXPERIENCE
Degree/Institution:
Degree/Institution:
Degree/Institution:
WORK EXPERIENCE
Title/Institution or Organization:
Title/Institution or Organization:
Title/Institution or Organization:
TEACHING & PRESENTATION EXPERIENCE (i.e. workshops, classes,
keynotes, etc.)
Title/Institution or Organization:
Title/Institution or Organization:
Title/Institution or Organization:
AWARDS, HONORS, & RECOGNITIONS (i.e. title, awarding institution,
etc.)
ACTIVITIES, PROGRAMS, & VOLUNTEER EXPERIENCE (i.e. dates,
institution, description, etc.)
REFERENCES
Name:
Title:
Institution:
Phone Number:
Name:
Title:
Institution:
Phone Number: