| * indicates required field |
*Presentation Title
(Please be creative but descriptive) |
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| Presenter Information |
*Presenter's Name (first, last): |
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Credentials: |
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Job Title: |
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Employer/Agency/University: |
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Mailing Address: |
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*Email Address: |
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*Preferred Telephone: |
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Fax: |
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| Secondary Presenter Information |
Presenter's Name (first, last): |
|
Credentials |
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Job Title: |
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Employer/Agency/University: |
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Mailing Address: |
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Email Address: |
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Preferred Telephone: |
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Fax: |
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| Publications: |
| Do you have published books you would like available at the bookstore? If so: |
Title: |
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Author: |
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Publisher: |
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| |
Title: |
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Author: |
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Publisher: |
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| Presentation Information |
*Length of presentation: |
2.0 hours
3.0 hours
6.5 hours
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*Appropriate for
participants with: |
less than 3 years work experience
more than 3 years work experience
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*Have you presented this session at another conference or workshop? |
Yes
No |
If yes, where and when? |
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*I consider this presentation to be advanced and applicable to supervisors and/or practitioners with 5 or more years experience in the addiction medicine field. |
Yes
No |
| *Track |
Please check all that apply: |
Administration
Criminal Justice
Recovery
Treatment
Prevention
Other
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*Number of participants your session can accommodate: |
(Note: Average size of concurrent sessions is 75-100 participants) |
| *Presentation Abstract (50 words or less): |
| This will appear in the brochure and should sell your session. It should be written so that participants will know exactly what is being presented. Proper names should not be included. |
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| Copyright Information |
If your presentation includes copyright information, you will obtain permission from the copyright holder? |
Yes
No |
| Education Materials |
Will handouts and slides contain any advertising, trade name or product group message? |
Will contain
Will not contain |
| *Equipment Needs |
| All meeting rooms used during the conference will be equipped with a screen, lectern and microphone. |
Please check all that apply:
(Presenter must bring his/her own laptop computer for PowerPoint presentation) |
Equipment for PowerPoint Equipment
VCR/DVD
Flip Chart
Overhead Projector
Sound System for CDs
None Needed
Other
If other, please specify:
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| *Required Room Set-up |
Please check only one: |
If other, please specify:
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| Special requests/comments |
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| Additional Required Forms |
|
In order to satisfy CEU requirements, all applications MUST
include a completed Biographical Data Form and Content Outline
for each presenter and session. Please download the two forms
listed below, complete the forms and save on your computer. Once
you have completed the online portion of the application, hit
submit and then email the two files to proposals@addictionstudiesinstitute.com IN
ORDER FOR YOUR APPLICATION TO BE CONSIDERED BOTH FILES MUST BE
INCLUDED AS WELL AS YOUR COMPLETE CURRICULUM VITAE OR RESUME.
To open forms right-click and select save target as.
Click
here to download the Biographical Data Form (MS Word)
Click
here to download the Content Outline Form (MS Word)
Click
here for a sample of a properly completed Content Outline Form
(PDF)
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