Co-Presenting Faculty Form (CE)

Divison of Continuing Education
Co-Presenting Faculty Form

If you have any questions while completing this form, contact Kellie Jones at kellie.jones@uky.edy or 859-644-7656
Co-Presenting Educational Activity Title
Personal Information:
Name:

First NameLast Name
Credentials:
Job Title:
Affiliation:
Employer/Company/Etc.
Email:
example@example.com
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
If you would like to designate a point of contact, do so here:
Name:

First NameLast Name
Email:
example@example.com
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.

Short Biography (to be published in materials, a CV or resume must be submitted separately and may be attached below):
Please upload a CV or resume:

Cancelof

Professional Headshot

This will be used in the CE flyer or brochure.
By signing your name below, you are providing a signature attesting that all the information completed on this form is true and correct to the best of your knowledge:
Date of signature:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Co-Presenting Faculty Form