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* 1. Speaker name

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* 2. Job title

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* 3. Organization

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* 4. Certifications/professional designations

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* 5. Mailing address (street, town/city, state, zip code)

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* 6. Phone number

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* 7. Email address

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* 8. Website URL

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* 9. Please enter a short bio explaining your professional experience generally.

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* 10. Have you presented at other industry conferences??

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* 11. Noteworthy articles and publications from the past 3 years (up to 5 items) include URLs if available

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* 12. Safety Summit 2019 will focus on several core areas: Safety Compliance, Risk Management, Safety Culture, Safety Leadership, and Safety Training. Please select no more than two area(s) for which you believe your proposed session(s) are best suited. (You will be asked to supply specifics on proposed title(s), learning objectives, etc. further down in the survey.)

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* 13. Please tell us which below best describes the format of your session:

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* 14. Please provide title(s), brief description(s), 3 to 4 learning objectives for your proposed session(s), and short explanation of the relevance of the proposed topic(s). If a workshop, please state proposed length of session (1 to 4 hours).

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* 15. What written materials, if any (not including PowerPoint slides) would you provide to the audience (e.g., pre-work assessments/evaluations, checklists, workbooks, etc.)? Please be as specific as possible when answering.

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* 16. Reference #1 (include name, company, mailing address, email address, phone number, and relationship--e.g, client, previously presented at conference, etc.) 

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* 17. Reference #2 (include name, company, mailing address, email address, phone number, and relationship--e.g, client, previously presented at conference, etc.) 

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* 18. Are you interested in sponsorship opportunities?

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* 19. Is there any other information you would like to share in support of your application to present at this conference?

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