Western Illinois University: Macomb Campus

Program Title: *

Short Description [topic of lecture, background or expertise of speaker, etc]: *

Date: *  (mm/dd/yyyy)

Time: *  (hh:mm am/pm)

Location: *

Sponsor(s): *

Type of Program (please check most appropriate): *

Admission Charge: *

Restrictions (if any):

Targeted Participants:

In case questions arise regarding this submission:

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Contact Name: *

Contact Email Address: *

Contact Telephone #: *  (XXX - XXX - XXXX)

Department Office #:

Contact person / info to be listed publicly on poster/news release (if different from above):

Name:

Email Address:

Phone:  (XXX - XXX - XXXX)