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This form is used for purposes of Continuing Education to provide documentation of an individual's expertise related to the program. Do not attach resume or curriculum vitae. Must be submitted for member(s) of the Planning Committee, presenter(s), and content specialist(s).

Check all that apply:

Check all that apply: Planning Committee

Faculty/Presenter

Content Expert

Target Audience

Please complete the following information:

Please complete the following information: Name:
Credentials:
Preferred Address:
Address 2:
City/Town:
State:
ZIP:
Country:
Preferred Email Address:
Preferred Phone Number:

We will use your cell phone number in an emergency only

We will use your cell phone number in an emergency only Cell Phone Number:

Please complete your employer information:

Please complete your employer information: Employer
Title
Description

Please complete your education (include basic preparation through highest degree held):

1st Institution

1st Institution Institution (Name, City, State)
Major Area of Study
Degree Awarded
Year Degree Awarded

2nd Institution (if necessary)

2nd Institution (if necessary) Institution (Name, City, State)
Major Area of Study
Degree Awarded
Year Degree Awarded

3rd Institution (if necessary)

3rd Institution (if necessary) Institution (Name, City, State)
Major Area of Study
Degree Awarded
Year Degree Awarded

Use this space below to briefly describe your professional experience or areas of expertise (including publications) related to your involvement in continuing nursing education and your particular role, e.g., planner, presenter, peer reviewer, administrator, etc. Planners also describe your familiarity with the target audience.
*DO NOT ATTACH RESUME. Please summarize below.

Use this space below to briefly describe your professional experience or areas of expertise (including publications) related to your involvement in continuing nursing education and your particular role, e.g., planner, presenter, peer reviewer, administrator, etc. Planners also describe your familiarity with the target audience. *DO NOT ATTACH RESUME. Please summarize below.

By submitting this form, I state that the information above is correct to the best of my knowledge.

BIOGRAPHICAL DATA FORM