First Name:  
Last Name:  
Email address:    
Work phone number:  
Emergency phone number:  
Course Title / Code (or Program where applicable):  
Date of Session (this would also be the anticipated date of our presentation):
 
Time: Start End
Length of Presentation:
 
Building and Room Number:
Room AV equipped?
 
Number of students:
 
Topic of discussion (Only two selections allowed):




Other:
 
Comments: