Committee Form

NORTHEAST REGIONAL NURSE PRACTITIONER CONFERENCE

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* 1. Committee Member Submitting:

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* 2. New or revised:

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* 3. Speaker

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* 4. Organization and Title

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

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* 6. Slot Number:

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* 7. Lecture Title:

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* 8. Date/Day/Time of Lecture:

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

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* 10. Objectives (limit 2-4):

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* 11. Comments:

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* 12. Home Address, City, State, Zip

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* 13. Contact Information
Home Phone:
Work Phone:
Cell Phone:
Email:

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* 14. Work Address, City, State, Zip

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