PHTA Webinar Series Call for Presenters Submission Form

PHTA Webinar Series
Call for Presenters Submission Form

First Name *

Last Name *

Title

Company *

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Office Phone: *

(555-777-1212)

Mobile Phone: *

(555-777-1212)

Email *

example@example.com

Website

Name(s) of proposed webinar presenter (s) (separate with commas) *

Speakers Credentials

Please select a topic area of the webinar

Session Length

Availability to present

Primary target audience

PHTA Member

Yes No

Webinar Title (20 words maximum)

Webinar description (300 words maximum) What is the main focus of the webinar? What are some possible resources that may be presented or used during the webinar?

Learning Objectives (Please list 3-5) By the end of this webinar, participants will be able to…

Has the content been presented or published by you or anyone else as a webinar or in a different format before?

Yes No

If Yes, please explain

Please provide any additional information we should consider when reviewing your submission

Please provide a brief bio for each presenter (100 words maximum) *

Instructor photo *

I agree that the information provided herein is true and accurate.

Yes

Name