The Clock is Ticking for Rural America

August 3-5, 2009

Presentation Proposal Submission Form

Please use this form to submit a proposal for a workshop or other type of presentation at the Clock is Ticking For Rural America Conference.  The conference planning committee will be considering proposals in spring 2009 and will notify speakers of their decision by the May 1, 2009.  Thank you for your interest in the behavioral health of agricultural people.

Please provide the following contact information for the presenter:

Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
E-mail

Please provide the following contact information for the co-presenter (if applicable):

Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
E-mail

Please provide a brief, one paragraph biography of the presenter:


Please provide a brief, one paragraph biography of the co-presenter (if applicable)


Please select one type of presentation


Please provide the title of your presentation


Learning Objective #1


Learning Objective #2


Please provide a brief description of your presentation



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Revised: 03/24/09