2019 NIEAPA Conference Presenter Proposal Form
41st Annual Conference
Tuesday, June 4, 2019
Drury Lane Conference Center, Oakbrook Terrace, IL

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

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.

Forms are due Friday, December 21, 2018.

Title: *
Ten words or less
Your answer
Presentation Format
Please check one *
Topic Area *
Skill Set and Levels
*
Beginner
Intermediate
Advanced
EAP Counselor
Account Management
Marketing and Sales
Presenter(s) - if more than two presenters, please list name and contact information of third presenter under Notes section at the end of this form.
First Name *
Your answer
Last Name *
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
Your answer
Credentials
Your answer
Title
Your answer
Organization
Your answer
Email
Your answer
Phone Number
Your answer
Contact information for whomever should receive communications
Name *
Your answer
Email *
Your answer
Phone *
Your answer
Fax
Your answer
Description of Presentation
Brief Description of the Proposed Session. *
Provide a brief description of the proposed session. Your description will be the template for the description published in the conference brochure and used by participants to select sessions. 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 into shorter sessions.
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. (Projector. laptop and microphones are provided. Additional A/V equipment may be available at the expense of the presenter)
Your answer
CV and Biography
Curriculum Vitae or Resume *
Or email to Tricia Fusilero - nieapa@corpevent.com. If you are emailing please type in "Email" in the response box below.
Your answer
Brief Biography *
Or email to Tricia Fusilero - nieapa@corpevent.com. If you are emailing please type in "Email" in the response box below.
Your answer
If available, please provide a link to a video of a past presentation you have given.
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 invited to join us for lunch and are encouraged to spend the day attending the Conference as our guest. NIEAPA asks that you refrain from promoting your business or services as part of your presentation at the Conference.
Notes
Please Include Any Additional Notes Here
Your answer
Email/Signature of Presenter(s) *
Your answer
Date *
Your answer
Proposal deadline is Friday, December 21, 2018.
Thank you for your interest in the NIEAPA 2018 Conference

Conference Chair: Peter Bradley, MA, LPC, CRADC
Illinois Institute for Addiction Recovery

If you have any questions about this form, please contact Tricia Fusilero at 312-756-7756 or nieapa@corpevent.com
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