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William F. Connell School of Nursing

Committee Form

northeast regional nurse practitioner conference


Salutation:

New or revised*:  New  Revised

*Note: Only add new or modified information


Today's Date:

 

Name:

Credentials:

(limit to three)

Position/Title:

 

Honorarium Requested:


(Breakout $250; Wednesday workshop $350; Breakfast $250)

Institution:



Letter to be sent to:             CV obtained/requested:

Home  Business           Yes  No


Committee Member Submitting:

 

Slot Number:

 

Lecture Title:

 

Date/Day of Lecture:

Start/End Time:

  

Session Description (limit 50-60 words):

  

Objective (limit to 2-4):

Comments 


Home Information

(Necessary for honorarium)

Address 1:

Address 2:

City/State/Zip:

Home:

Cell:


(Will only use as emergency notification on day of conference)

Business Information

Address 1:

Address 2:

City/State Zip:

Phone:

Office/Secretary Phone:

 

Fax/Email: