Program Proposal Form

Use this form for collecting and storing information on presenters for GPLS-sponsored events.

Submitter

Name: *

Program Information

Program Title: *

Program Type: *

Start Date: *

End Date: *

Start Time: *

End Time: *

Description of Program: *

Location: *

Objective 1: *

Objective 2:

Objective 3:

Estimated Hours of CE Credit:

Do not include time alloted for breaks or meals

Ideal Audience Size:

Equipment/Room Setup Requests:

Speaker Fees:

Explanation of Speaker Fees:

Please provide an itemized detail of requested speaker fees, including items such as honorarium, lodging, and travel expenses.

Presenter

First Name: *

Last Name: *

Position: *

Organization: *

Address: *

City: *

State: *

Zip: *

Email: *

Phone: *

Biographical Info: *

Presenter 2

First Name:

Last Name:

Position:

Organization:

Address:

City:

State:

Zip:

Email:

Phone:

Biographical Info:

Presenter 3