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Email
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Your email
Name of Institution/Organization
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Your answer
Contact Name
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Your answer
Email Address
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Your answer
Location of Engagement (City, State OR Virtual)
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Your answer
Date of Engagement or Proposed Start Date
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MM
/
DD
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YYYY
Time of Engagement
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Time
:
AM
PM
Type of Engagement
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Keynote
Panel
Workshop
Series
Other:
Time Commitment
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30 minutes
60 minutes
90 minutes
120 minutes
1/2 Day
Full Day
Other:
This engagement is for? (check all that apply)
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Faculty
Students
Administrators
Support staff
Combination of the above
Other:
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How many participants are expected?
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Your answer
Do you have a particular theme you would like addressed?
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Yes
No
NA
If yes, what is your conference, symposium, or series theme?
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Your answer
What is your speaker/facilitator budget for this engagement?
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Your answer
If you selected "Other" in any of the above categories, feel free to clarify in this section?
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