PD on Demand & Rutger Dimacs Workshops - Speakers' Bureau Submission Form
The information requested on this form is, in part, so that we have critical information for you on file that can be supplied to those who may be requesting your services. It is much easier to have this information readily available, rather than having to reach out to you when time may be of the essence. As an example, many Boards of Education require the kind of information requested here, so we would prefer to be prepared in advance.

Fees will be equally shared between the presenter and the AMTNJ (50%/50%) for the first presentation for PD on Demand. Subsequent sessions with the same people (or organization) would be shared between the presenter and AMTNJ at an increased rate for the presenter at (70%/30%) for the subsequent two years. Presenters may not advertise or sell products during their sessions. Compensation amount for the Rutgers Workshops have not been determined yet.

AMTNJ would expect that with regard to the relationship formed between a speaker and the people (or organization) who hired that speaker through AMTNJ, that the speaker and the organization would not enter into a separate arrangement for an independent workshop for at least two years from the date of the initial presentation. If the speaker is asked to do a subsequent independent presentation by another person or organization as a direct result of their having experienced the workshop that was sponsored by AMTNJ, AMTNJ would expect that the same two year window would be honored. Submitting this form indicates acceptance of these terms by the applicant.

The applicant may be asked to present at an AMTNJ function before acceptance.

(Please note: Information may be copied and pasted into this document from other sources.)

Title *
Please enter your preferred title - If other, please also complete the follow-up question.
Other Title
If your answer to the previous question was "Other", please complete this item.
Your answer
First Name *
Please enter your first name.
Your answer
Last Name *
Please enter your last name.
Your answer
Street Address *
Please enter your preferred street address for mailings.
Your answer
City *
Please enter the town or city of your preferred address.
Your answer
State *
Please choose your preferred state address.
Other State
If you chose "Other" for the previous question, please enter your state here.
Your answer
Zip Code *
Please enter the zip code for your preferred mailing address.
Your answer
Phone Number *
Please enter your preferred contact phone number (including area code).
Your answer
Type of Phone Contact *
Please select the type of phone contact.
Other Phone
Please enter the type of phone contact if it was not listed in the prior question.
Your answer
Email Address *
Please enter your preferred email address.
Your answer
Type of Email Contact *
Please indicate the location of your email address.
Other Email
If your email contact was not home or work, please indicate its location here.
Your answer
Leading Affiliation *
Please enter your current employment location or the organization with whom you are most closely associated.
Your answer
Additional Affiliation(s) (optional)
If you have any additional affiliation(s) that you want noted, please enter it (them) here.
Your answer
Foremost Experience Descriptor(s) *
Please choose the job title(s) that best describe your most predominant experience(s).
Required
Professional Responsibilities *
Please briefly describe the main responsibilities that describe your experiences. (Please limit to about 50 words.)
Your answer
Grade Bands/Audience *
Please enter as many grade bands and/or groups to whom you are comfortable presenting.
Required
Areas of Expertise *
Please check off as many broad areas of expertise with which you are comfortable presenting.
Required
Availability *
Please indicate all of the times that you would be available to make presentations or workshops.
Required
Years of Experience in Education *
Please indicate the number of years that you have been involved in education.
Years of Experience in Professional Presentations *
Please indicate the number of years that you have been speaking or providing professional development
Multi-Day Workshops *
Are you willing to consider doing multi-day workshops?
Follow-Up Sessions *
If your group would like additional sessions, would you consider providing them?
First Reference *
Please enter the name, address, phone number, email address, and affiliation of your first reference.
Your answer
Second Reference *
Please enter the name, address, phone number, email address, and affiliation of your second reference.
Your answer
Third Reference *
Please enter the name, address, phone number, email address, and affiliation of your third reference.
Your answer
Recent Presentations (1) *
Please enter the title, location, date, audience, and a brief description (approximately 50 words) of a recent presentation (1).
Your answer
Recent Presentation (2) *
Please enter the title, location, date, audience, and a brief description (approximately 50 words) of a recent presentation (2).
Your answer
Recent Presentation (3) *
Please enter the title, date, location, audience, and a brief description (approximately 50 words) of a recent presentation (3).
Your answer
Would you be interested in speaking for AMTNJ at a Summer Institute? *
Please be aware that the rate of compensation is different (lower) for Summer Institutes. Please review the information for speaking at Summer Institutes.
Additional Information
Please provide any additional information that you believe would be helpful to have on record.
Your answer
Resume
Please send your most recent resume to Dianna M. Sopala at diannamsopala@yahoo.com just in case a district requests it.
Your answer
PD on Demand or Rutgers Dimacs Workshops *
Are you interested in presenting at the Rutgers Dimacs Workshops or for PD on Demand or both.
Title of Rutgers Dimacs Workshops
What is the title of your workshop for 2017-2018 school year?
Your answer
Rutgers Dimacs Workshop Workshop Descrition
What is the workshop description?
Your answer
What date during the 2017-2018 school year do you want to present your Rutgers Dimacs workshop?
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