Webinar Proposal Form Applicant Information Full Name: Last
First
M.I.
Address: Street Address
Apartment/Unit #
City
Home Phone:
State
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ZIP Code
Email Address:
Membership or Affiliation to Partners:
Webinar Information Use as much space as needed to fully answer each question. Feel free to add additional information at the end.
Proposed Webinar topic(s) or title(s): _____________________________________________________________________________________ _____________________________________________________________________________________ Proposed Speaker(s):______________________________________________________________________ Credentials of Proposed Speaker on Chosen Topic: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Familiarity of Speaker with online media and PowerPoint: (1=not familiar and 5=very familiar)
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Language preferences of presenter: ________________________________________________________ Suggested dates for Webinar or availability of speaker: _____________________________________________________________________________________