Call for Speakers - 2012 Nevada Health Conference

As a confirmed speaker for the 2012 Nevada Health Conference: A Focus on Immunizations and MCH set for Thursday and Friday, November 1—2, 2012 we ask that you complete the following form. Should you have any questions or concerns, please contact Emily Stratton at .

Please note: The information provided below will be used for the conference program and website conference promotion. Details provided by the speaker will be used verbatim in these promotional pieces. Should any changes be made, Immunize Nevada will contact you directly for approval.

First Name: *

Last Name: *

Organization: *

Title: *

Credentials (i.e. M.D., MPH, F.A.A.P., etc.): *

E-mail: *

Phone Number: *

Provide a brief biography description (200 words or less): *

What is the title of your workshop?: *

Provide a brief description of your workshop topic (100 words or less): *

Provide 3-5 objectives for your workshop topic.: *

If you are presenting more than one workshop, what is the title of your second workshop?:

If you are presenting more than one workshop, provide a brief description of your workshop topic (100 words or less):

If you are presenting more than one topic, provide 3-5 objectives for your second workshop topic.:

May we provide your contact information in the conference program?: *

Yes

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