2025 Presenter Registration Form

2025 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 NameLast Name
Are there multiple presenters:*

YesNo
Are you a co-presenter?*

YesNo
Presenter #2

First NameLast Name
Presenter #3

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number:*

Area CodePhone Number
Cell Number:

Area CodePhone Number
Fax Number:

Area CodePhone Number
E-mail:*
Please list any pertinent educational experience outlining relevant expertise pertaining to the educational objectives of the presentation:*
Please list any licenses, certifications, or awards received:*
CHES #
Please feel free to upload your resume along with this application. (Optional)

Upload a File

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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 3Monday, March 4Tuesday, March 5I 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 2Monday, March 3Tuesday, March 4I do not require a complimentary registration including meals
Section C - Additional Conference Day Registrations
My Products:
prevnext( X )
Sunday, March 2$125.00

Monday, March 3$125.00

Tuesday, March 4$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:*

LaptopLCD ProjectorMicrophoneInternet
Other:
Section E - Presentation Information
Brief description of presentation:
Summary of course objectives, new skills or proficiencies this course conveys to participants:
Describe learning objectives and topics to be covered:
*

Please indicate your 1st, 2nd, and 3rd choices for the presentation date and time you prefer:
1st choice:*
2nd choice:*
3rd choice:*
Please Indicate the amount of time your presentation will require (including 15 minutes for Q & A following presentation):*

1. 5 hours3.0 hours
Do you wish to be introduced before your presentation by a Proctor or would you prefer to introduce yourself? If you answer yes please put description below.

Proctor IntroductionSelf Introduction
Introduction:
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:*

ResearchConsultantShareholderSpeaker/ Speaker BureauOther Financial SupportI have no financial interest(s) to disclose
Unlabeled and Unapproved uses of products:*

Not ApplicableI 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 online.
Final Submission is January 15, 2025
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).
Should be Empty:

2025 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 E - Presentation Information

*

Section F - Speaker Disclosure

Section G - Permissions

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 online.

Final Submission is January 15, 2025

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).