*Name of Contact Person:

*Phone of Contact Person:

E-mail of Contact Person:

Address of Contact Person:

                   Address Line 2:

*Proposed Location of Workshop:

Preferred dates (list up to 5 in order of preference):

PLEASE LIST IN FOLLOWING FORMAT:   1st Choice: Date Monday, January 2  Time 7:00 PM

*1st choice: Date Time

2nd choice: DateTime

3rd choice: DateTime

4th choice: DateTime

5th choice: DateTime

What type of audience do you expect?

All/mostly Undergraduate

All/mostly Graduate

Other

Anticipated group size:

Male/female ratio: /

Other comments: