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UWCNE Speaker Information for Brochure Form

This form is to be used to gather information when the speaker accepts.

Conference Information

Conference Title:

Conference Date(s):

Your Name:

Your Phone:

 

Information for Brochure and Speaker Confirmation Letter

Speaker's First Name:

Speaker's Middle Initial:

(opt. leave off puncutation)

Speaker's Last Name:

Degrees/Credentials:

Position/Title:

Other Relevant Positions:

Department:

Agency:

Agency Address:

Agency Address:

Agency City:

Agency State:

Agency ZIP:

Daytime Phone:

FAX Number:

E-mail:

 

College/University Affiliation (If different from above)

Academic Title:

College/University:

College City:

Where should confirmation letter be sent?

Work Home

Home Address:

Home City:

Home State:

Home ZIP:

 

Presentation Information

Type of Presentation:

Plenary Session    Concurrent Session
Saturday Workshop Special Interest
Keynote

Track:

Title of Presentation:


(As it should appear in the brochure.)

Length of Presentation

Min. (Including 10 min. for questions.)

Key Topics (To be included in the confirmation letter as a reminder.)

Topic 1.

Topic 2.

Topic 3.

Topic 4.

Topic 5.

 

Scheduling Information

Day of week and date of presentation:

Beginning Time:

Ending Time:

Is speaker flexible if time needs to be changed?

Yes No

Is the standard UWCNE honorarium acceptable?

Yes No

Will more than 50% of the session be related to pharmacology: (See Pharmacology Guidelines)

Yes No

 

Sponsorship Information
Please complete the information below if the speaker knows of a company that might want to exhibit or provide an educational grant to UWCNE because of the speaker's presentation.

Company Name:

Rep's Name:

Rep's Phone:

Who contacted the rep?

Speaker PC Member

PC Member Name:

Company Involvement:

Confirmed Pending

Support Amount:

$

Rep's Interest:

Sponsor speaker expense Exhibit at conference Provide education grant

 






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The University of Washington is committed to providing access, equal opportunity and reasonable accommodation in its services, programs, activities, education and employment for individuals with disabilities. To request disability accommodation, contact the Disability Services Office at least ten days in advance of a conference at: 206-543-6450/V, 206-543-6452/TTY, 206-685-7264 (FAX), or dso@u.washington.edu.