CEU Program Proposal Form

First Name *

Last Name *

Email Address *

Phone Number *

Agency, Organization or Affiliation *

Job Title *

Are you the presenter or a provider?

Presenter

Provider

PRESENTER INFORMATION

Presenter First Name *

Presenter Lasst Name *

Presenter Email *

Presenter Phone *

Please enter your bio here (You may copy and paste in this area)

PRESENTER REFERENCE INFORMATION

Full Name (Reference 1) *

Phone (Reference 1) *

Email (Reference 1) *

Full Name (Reference 2) *

Phone (Reference 2) *

Email (Reference 2) *

EVENT INFORMATION

Event Title *

Event Date *

Proposed Event Location *

Event Abstract *

Event Goal(s) *

Event Learning Objective(s) *

Event Agenda *

Level of practice

Introductory

Intermediate

Advanced

All of the above

Other…

If other than any of above enter details here

Instructional Method(s) *

Evidence Based Practice References *

Additional Comments or Details *

Please upload copy of the presenter's CV or resume

One file only.
256 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

Please upload any additional/supporting documentation

One file only.
256 MB limit.
Allowed types: gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, mp4, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.

CAPTCHA

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

If you have an accessibility issue with completing the CAPTCHA provided in this form, please email webaccessibility@louisville.edu to report your web accessibility issue or accommodation request.

Quick Links

Menu

Site Search

CEU Program Proposal Form

Phone:

Email:

Hours:

Address: