When you have completed the form, EITHER: 1. Save it and email as an attachment to the Center's Administrative Assistant OR 2. Print the form and fax to 402-552-2769 Presenter name: it is not necessary to complete your contact information if a speaker application form has already been submitted. thank you Address: City: State: Zip: phone: alternate phone: email: please complete this information for each presentation given, thank you Date given: Location (building/organization/ etc): City: County: State: Contact name/phone/email of representative of group or organization name: phone: email: Audience (check all that apply): general public university high school elementary school civic or business organization church Healthcare institution/Hospital, etc. other Presentation given: general layperson advanced layperson Healthcare presentation Comments:
When you have completed the form, EITHER:
1. Save it and email as an attachment to the Center's Administrative Assistant OR 2. Print the form and fax to 402-552-2769
Presenter name:
it is not necessary to complete your contact information if a speaker application form has already been submitted. thank you
Address: City: State: Zip:
phone: alternate phone: email:
please complete this information for each presentation given, thank you
Date given:
Location (building/organization/ etc):
City: County: State:
Contact name/phone/email of representative of group or organization
name: phone: email:
Audience (check all that apply): general public university high school elementary school civic or business organization church Healthcare institution/Hospital, etc. other
Presentation given: general layperson advanced layperson Healthcare presentation
Comments:
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Center for Biopreparedness Education 984550 Nebraska Medical Center Phone: (402) 552-2529 Fax: (402) 552-2769 Email: Center@bioprepare.org
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