Co-Presenting Faculty Form (CE)

Divison of Continuing Education
Co-Presenting Faculty Form

If you have any questions while completing this form contact Megan McNeal at megan.mcneal@st-claire.org or 606-783-7578.
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.
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.

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:*

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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: *

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Date of signature: *

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Date

Co-Presenting Faculty Form