NP Committee Form

Committee Form

NORTHEAST REGIONAL NURSE PRACTITIONER CONFERENCE

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* 1. Salutation:

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* 2. New or revised:

New

Revised

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* 3. Today's Date:

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* 4. Name:

First

Last

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* 5. Credentials: (limit to three)

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* 6. Position/Title:

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* 7. Honorarium Requested: (Breakout $250; Wednesday workshop $350; Breakfast $250)

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* 8. Institution:

Institution

Conf. Supported

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* 9. Letter to be sent to:

Home

Business

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* 10. CV Obtained/Requested:

Yes

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* 11. Committee Member Submitting:

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* 12. Slot Number:

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* 13. Lecture Title:

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* 14. Date/Day of Lecture:

Date

Day

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* 15. Start/End Time:

Start Time

End Time

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* 16. Session Description (limit 50-60 words):

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* 17. Objectives (limit 2-4):

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* 18. Comments:

HOME INFORMATION

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* 19. Address 1:

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* 20. Address 2:

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* 21. City/State Zip:

City

State

ZIP

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* 22. Home Phone:

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* 23. Cell Phone:

BUSINESS INFORMATION

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* 24. Address 1:

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* 25. Address 2:

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* 26. City/State Zip:

City

State

ZIP

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* 27. Office:

Phone

Fax