Western Illinois University Mathematics Department

High School Presentation Request Form

(please duplicate and add pages as needed)

TEACHER NAME _____________________________________________________________
SCHOOL PHONE _____________________ E-mail______________________________

Preparation period (or best times to call) _____________________________________________

SCHOOL _____________________________________________________________________

ADDRESS ____________________________________________________________________

______________________________________________________________________________

******************************************************************************

Class #1 ______________________________ Meeting time ________________________

Preferred Presentation Title/Speaker ________________________________________________

________________________________________________

Please add any helpful specifics (preferred dates, day of week, block schedule, etc.)

______________________________________________________________________________

******************************************************************************

Class #2 ______________________________ Meeting time ________________________

Preferred Presentation Title/Speaker ________________________________________________

________________________________________________

Please add any helpful specifics (preferred dates, day of week, block schedule, etc.)

______________________________________________________________________________

******************************************************************************

Class #3 ______________________________ Meeting time ________________________

Preferred Presentation Title/Speaker ________________________________________________

________________________________________________

Please add any helpful specifics (preferred dates, day of week, block schedule, etc.)

______________________________________________________________________________

******************************************************************************

Return to: Bob Mann

Department of Mathematics

Western Illinois University

1 University Circle

Macomb, IL 61455

Or email the appropriate information to: RR-Mann@wiu.edu

Or fax to Bob Mann at 309-298-1857