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University of Texas Health Science Center at San Antonio Biographical Data Form

The information you will provide below will be used for continuing education purposes for the activity or workshop that your are affiliated with. We ask that you provide your expertise for this activity.

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* 1. What is the name of the conference you are completing this form for?

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* 2. What is the date of the Conference?

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* 3. Check all the roles you are fulfilling (you can choose more than one if applicable):

Biographical Data
Use the space below to briefly describe your professional experience as it relates to your role, as indicated above, in this continuing nursing education activity. Based on the role(s) checked above, complete the appropriate following statement:

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* 4. As Presenter/Author, I have content expertise specific to this education activity by:

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* 5. As Planning Committee Member, my professional experience as it relates to this continuing nursing education activity is:

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* 6. Last Name:

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* 7. First Name:

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* 8. Middle Name or Initial:

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* 9. Credentials Example (MD, PhD, RN, MSN)

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* 10. Mailing Address:

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* 11. City, State & Zip Code:

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* 12. Preferred Contact Telephone Number:

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* 13. Email Address:

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* 14. Current Employer:

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* 15. Position Title:

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* 16. Are you a speaker or poster presenter?



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