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NIEAPA Chapter Meeting Presenter Proposal Form
No presentation will be considered if a proposal form has not been submitted. Meeting dates, times and locations of chapter meetings vary. A member of our program committee will contact you to confirm your availability for a specific meeting.

NIEAPA chapter meeting attendees include employee assistance program managers, benefit managers, clinical psychologists, medical directors, social workers, counselors and community liaisons. Our chapter meetings are an excellent opportunity to connect with the EAP community and raise awareness of topics or issues that you believe the community would be interested in learning about.

Please note that this online form does not allow you to save your responses and reopen at a later date to complete. If you prefer a form you can print out and complete please contact Tricia Fusilero at 312-756-7756 or NIEAPA@corpevent.com.

Instructions:
Fill out this form with the appropriate information, clicking submit when the form is complete. You can make revisions as needed prior to submitting the form.
Title: *
Five words or less
Your answer
Please confirm that your presentation is 2 hours long (for CEU Purposes) *
Presenter(s) - if more than two presenters, please list others in the Notes section at the end of this form.
Name of 1st Presenter *
Your answer
Credentials
Your answer
Title
Your answer
Organization *
Your answer
Address, City, State, Zip
Your answer
Email *
Your answer
Phone Number *
Your answer
Fax Number
Your answer
Second Presenter
Name of 2nd Presenter (if applicable)
Your answer
Credentials
Your answer
Title
Your answer
Organization
Your answer
Description of Presentation
Program Description *
Provide a brief description of the proposed session. Your description will be the template for the description published in the workshop announcement. Please be thoughtful and concise.
Your answer
Learning Objectives *
In order for your proposal to be considered, you must list the specific learning objectives for the session. Please be consistent with selected presentation format and participant level. Do not attempt to include too much information.
Your answer
Outline *
How will you structure your presentation? (i.e. lecture, discussion. video, group exercises, case studies) If you will need audiovisual support, please list your requirements here. If you plan to use PowerPoint, it will be necessary to bring your own laptop.
Your answer
CV and Biography
Curriculum Vitae or Resume *
Or email to Kelly Collins - nieapa@corpevent.com. If you are emailing please type in "Email" in the response box below.
Your answer
Brief Biography *
Or email to Kelly Collins - nieapa@corpevent.com. If you are emailing please type in "Email" in the response box below.
Your answer
References
Please list the names, telephone numbers and email addresses of at least three people who can discuss your ability to speak about your proposed topic.
Name of 1st Reference *
Your answer
Title/ Organization
Your answer
Email *
Your answer
Phone *
Your answer
Name of 2nd Reference *
Your answer
Title/ Organization
Your answer
Email *
Your answer
Phone *
Your answer
Name of 3rd Reference *
Your answer
Title/ Organization
Your answer
Email *
Your answer
Phone *
Your answer
Persons who are selected to present are encouraged to come to the networking portion of the meeting, just prior to the presentation. NIEAPA asks that you refrain from promoting your business or services as part of your presentation.
Notes and Confirmation
Please Include any Additional Notes Here
Your answer
Email/Signature of Presenter(s) *
Your answer
Date: *
Your answer
Thank you for submitting a proposal to the Northern Illinois Employee Assistance Professionals Association!
If you have any questions about this form, please contact Tricia Fusilero at 312-756-7756 or nieapa@corpevent.com.

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