Workshop Application - Advanced Automation, Robotics, and Manufacturing Education
for 21st Century Workforce Needs

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* 1. Contact information

Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

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* 2. Employment information

Title

Institutional affiliation

Department

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* 3. Please list the courses that you've taught in past 3 years:

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* 4. Please list the courses that you plan to teach in the next 2 years:

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* 5. Please list your degree(s), diploma(s), and certification(s) below, including your major or focus area.

Ph.D.

Masters

Bachelors

Diploma

Certification

Other

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* 6. Why are you interested in attending this workshop?

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* 7. How do you plan to use what you learn from this workshop?