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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 the speaker's professional experience generally.

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* 10. Has the speaker 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. Which topic area (select one only) is the speaker prepared to present on?

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* 13. Please provide a title, brief description, and 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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* 14. What makes you uniquely qualified to present on this topic for California safety professionals?

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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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