Vendor Presentation Committee Application

Sponsor Information (RSDM department or person)
Name:
Telephone:
Fax:
Email:
Activity Information
Title:
Proposed Date(s):
# Hours:
Contact Information (from company/organization)
Contact Person:
Address:
Mail Stop or P.O. Box:
City:
State:
Zip:
Telephone:
Fax:
Email:
Other:
Goals of Presentation
What is to be accomplished?
What benefits will be gained by attending?
Who is the proposed audience or consumer?

Proposed Agenda
Include topics, outline, module display, inclusive times and participating speakers.
Presentation Method
Traditional (lecture hall/classroom/clinic or lab) Teleconferences (audio)
Mini-Residencies/Fellowships Internet
Videoconferences Other:
Enduring Materials/Handouts (Neither solicitation nor personal information can be attached to the distribution of this material.)
Newsletter/Monograph Audiotapes Journal Article/Supplement
Videotape CD-ROM Other:
DVD Internet
Food Will Be Provided 
YES  NO