Releasing Technology Workshop Application

Title of Presentation:

Number of Hours for Workshop:
One-Hour Workshop - $1100
Two-Hour Workshop - $1855

120-word Description of workshop:

Educational Goals:

Prospective Attendees:

First Name:

Last Name:

Title:

Specialty or Discipline:

Affiliation:

Address 1:

Address 2:

City:

State/Province:

Postal Code/ Zip:

Country:

Telephone:

Facsimile:

Email:

Other Email: