BIOGRAPHICAL DATA FORM Boston College William F. Connell School of NursingContinuing Education Program 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). Question Title Check all that apply: Planning Committee Faculty/Presenter Content Expert Target Audience Question Title Please complete the following information: Name: Credentials: Preferred Address: Address 2: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Country: Preferred Email Address: Preferred Phone Number: Question Title We will use your cell phone number in an emergency only Cell Phone Number: Question Title Please complete your employer information: Employer Title Description Please complete your education (include basic preparation through highest degree held): Question Title 1st Institution Institution (Name, City, State) Major Area of Study Degree Awarded Year Degree Awarded Question Title 2nd Institution (if necessary) Institution (Name, City, State) Major Area of Study Degree Awarded Year Degree Awarded Question Title 3rd Institution (if necessary) Institution (Name, City, State) Major Area of Study Degree Awarded Year Degree Awarded Question Title 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. Submit