NHHSS & Center for Biopreparedness Education
Avian Flu Speaker Application Form

When you have completed the form, EITHER: 1. Save it and email as an attachment to the Center  OR         2. Print the form and fax to 402-552-2769
Please complete and indicate your availability to deliver avian flu presentations
Name (incl. title):
Address:
City          County         State      Zip
Phone:	Alternate phone:
Profession:    physician    nurse   public health professional    educator (k-12, higher ed, etc.)   other
Affiliation (optional):
Available to present:   my city/town      my county   my region     anywhere in state  other