2023 Co-Presenter Registration Form

2023 Co-Presenter Registration Form
Please fill out form in its entirety
Section A - Personal Information

Please note information from this section will be included in the conference packet that is given to attendees.
Presentation Title: *
Presenter *

First Name Last Name
Credentials: *
Job Title: *
Organization/ Employer: *
Business Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number: *

Area Code Phone Number
Cell Number:

Area Code Phone Number
Fax Number:

Area Code Phone Number
E-mail: *
Please list any licenses, certifications, or awards received: *
CHES#
Please feel free to upload your resume along with this application. (Optional)

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Section B - Complimentary Amenities

One complimentary one-night hotel accommodation is included for each presenter. Please indicate which night you would prefer for your complimentary one-night hotel accomodation. Additional nights of accommodation must be arranged directly with the Tropicana.
Complimentary Amenity Preference: *

Sunday, March 5 Monday, March 6 Tuesday, March 7 I do not require any hotel accommodations
*

One complimentary one-day registration (includes educational sessions and meals) is included for each presenter). Please indicate which day you would prefer for your complimentary one-day registration. Additional days of registration require payment.
Complimentary Registration Choice: *

Sunday, March 5 Monday, March 6 Tuesday, March 7 I do not require a complimentary registration including meals
Section C - Additional Conference Day Registrations
My Products:
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Sunday, March 5 $ 125.00

Monday, March 6 $ 125.00

Tuesday, March 7 $ 125.00

2 Day Registration $ 200.00

Total $ 0.00
Should you choose to pay by check or purchase order please print this form and mail payment and form to: ( Do Not hit the Submit Button at the end if paying by check otherwise you will be redirected to PayPal)

New Jersey Environmental Health Association-One Dag Hammarskjold Boulevard, Suite 6, Freehold, NJ 07728
Section D- A/V Equipment
Please indicate below the audio visual equipment that you will need for your presentation: *

Laptop LCD Projector Microphone Internet
Other:
Section F - Speaker Disclosure
Describe any financial interest(s) with the commercial supporter of this educational program and any product or device related to your presentation:
Please check off any response and describe in detail above: *

Research Consultant Shareholder Speaker/ Speaker Bureau Other Financial Support I have no financial interest(s) to disclose
Unlabeled and Unapproved uses of products: *

Not Applicable I intend to discuss either non-FDA approved or investigational use of the following products or devices
Section G - Permissions

NJEHA posts information and media from our conference on our website (http://www.njeha.org) for about 6 months after the conference, and includes read-only versions of PowerPoint presentations, photos, and videos.
Do we have your permission to post a read-only file of your presentation on www.njeha.org? *
Do we have your permission to post photographs in which you and/or your presentation are inculded on www.njeha.org? *
Do we have your permission to post videos in which you and/ or your presentation are included on www.njeha.org? *
Please note that presentations can be transferred via USB flash drive (MS Power Point 2003 or 2007 compatible). Since we cannot guarantee compatibility with all multimedia formats (DVD video, QuickTime video, DirectX, Adobe Flash player, etc.) you are urged to submit your presentation ahead of time online.
Final Submission is January 15, 2023
Participants who complete this educational program will be awarded NJ Public Health Continuing Education Contact Hours (CE's). NJEHA has been approved by the New Jersey Department of Health and Senior Services as a provider of NJ Public Health Continuing Education Contact Hours (CE's).
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2023 Co-Presenter Registration Form

Please fill out form in its entirety

Section A - Personal Information

Section B - Complimentary Amenities

*

Section C - Additional Conference Day Registrations

Should you choose to pay by check or purchase order please print this form and mail payment and form to: ( Do Not hit the Submit Button at the end if paying by check otherwise you will be redirected to PayPal)

Section D- A/V Equipment

Section F - Speaker Disclosure

Section G - Permissions

Final Submission is January 15, 2023

Participants who complete this educational program will be awarded NJ Public Health Continuing Education Contact Hours (CE's). NJEHA has been approved by the New Jersey Department of Health and Senior Services as a provider of NJ Public Health Continuing Education Contact Hours (CE's).