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* 1. Instructor Last Name

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* 2. Instructor First Name

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* 3. Instructor E-mail

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* 4. Instructor Address (Street # and name)

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* 5. Instructor Address (City, State, Zip)

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* 6. Instructor Phone (Best number to use)

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* 7. Instructor Credentials (EMT, RN, MD, Etc.)

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* 8. Do you require Assistant Instructors

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* 9. If the answer to #8 was yes, please explain why

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* 10. The conference is scheduled for November 6 - 10. Are there any of these days where you cannot teach? Please list.

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* 11. Available time lengths for the preconference are 4 hours and 8 hours, and the regular conference sessions are scheduled in 1-hour blocks. How many sessions are you submitting? Please indicate how many 4-hour, 8-hour, and 1-hour sessions you are submitting.

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* 12. Session 1 Title and Length

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* 13. Session 1 Brief Description

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* 14. Session 2 Title and Length

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* 15. Session 2 Brief Description

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* 16. Session 3 Title and Length

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* 17. Session 3 Brief Description

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* 18. Session 4 Title and Length

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* 19. Session 4 Brief Description

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* 20. We typically provide Instructors with a hotel room either the night before or after their session(s), free attendance to any other program at the conference (except for any certification fees or books), and a banquet ticket. Do you require any other honorarium for presenting at the conference?

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