Western Illinois University: Macomb Campus

First Name: *

Last Name: *

Title: *

Department or Organization: *

Campus Address: *

Phone Number: * (XXX-XXX-XXXX)

Email Address: *

Best Way to be Reached: * Phone Email

Please provide three dates/times that would work for your staff with your preferred date/time listed first. We will do the best to accommodate the dates and times that are listed.

Presentation Date/Time (1): *  (mm/dd/yyyy)

Presentation Date/Time (2): *  (mm/dd/yyyy)

Presentation Date/Time (3): *  (mm/dd/yyyy)

Estimated Attendance: *

Location: *

* Location can be set up by Western Connect Committee if needed.

Service Provided to: * Faculty Staff Graduate Students Undergraduate Students

Technology Available: Computer Projector

Please add any information that you think might aid in planning this presentation: