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    Your Name (required):
    Your Email (required):

    Course/Event Information

    Subject or Course Title
    Instructor/presenter name(s) (if applicable)
    Description of Event/Course
    Instructor/presenter contact information during course/event (if applicable)
      Instructor/presenter provided equipment (if applicable)
    PC Laptop, MAC Laptop, overhead projector, etc.

    Daily Start Time
    Daily End Time
    If the times of the course vary, please list the times in the Special Instructions field.

    Primary Requested Dates (mm/dd/yyyy)
    Start Date:   End Date:
    Alternate Requested Dates (mm/dd/yyyy)
    Start Date:   End Date:

    Event Type

    Anticipated Number of Attendees

    Equipment/Room Requirements

    Wireless Internet Connectivity Available Throughout Facility

    Participants to use their own laptopsN/A

    Please Indicate Equipment Required  
    Flip Charts How Many? 
    Breakout Rooms How Many? 
    Video Recording Event  
    Presenter Table  
    Mobile Marker Boards  

    Choose Room Layout  
    Classroom Style
    Pod Style

    POC / Alternate POC Information

    POC Name
    POC Email Address
    POC Phone Number
    Alternate POC Name
    Alternate POC Email
    Alternate POC Phone Number
    Instructor Type (required)
      Instructor Arrival Time

    Special Instructions

    Please type in the characters you see below in the field provided: