SPEAKER DATA FORM FOR MASSACHUSETTS ENA PROJECTS
TRIAGE COURSE/CEN REVIEW COURSE


Name:_____________________________________ Credentials: ________________

Home address: _________________________________________________________

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Home phone: _______________________ E-mail address: ______________________

Fax: _______________________________

Job Title: _____________________________________________________________

Employer: _____________________________________________________________

Work address: _________________________________________________________

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Work phone: _______________________ E-mail address: ______________________

Fax: _________________________________________________________________

Education (School, degree, year of graduation):

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Lecture topics: ________________________________________________________

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Background experience/expertise related to lecture topics: _______________________

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Availability (best days of week, preferred time of day, days vs evenings, etc.):

____________________________________________________________________

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Are you willing to travel to give lectures? How far? : ____________________________

____________________________________________________________________

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Special considerations, comments, suggestions: _________________________________

____________________________________________________________________

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Thanks so much for agreeing to be part of the Massachusetts ENA Speakers Bureau. Please return this bio data sheet to:

Robin Walsh
76 Cushman Rd
Leverett, MA 01054
(413) 549-9139
rwrn627@aol.com


**Please keep us updated on any changes in the above information.