AMERICAN DENTAL HYGIENISTS' ASSOCIATION
AMERICAN DENTAL HYGIENISTS' ASSOCIATION
AMERICAN DENTAL HYGIENISTS' ASSOCIATION
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2014 ADHA CLL at the 91 th Annual Session<br />
CE Program Proposal Submission Form<br />
2014 CONTINUING EDUCATION PROGRAM PROPOSAL<br />
Course Title: ________________________________________________<br />
Speaker(s):_______________________________________________________<br />
Speaker Bio(s) (please limit to a paragraph):<br />
Short Speaker Vitae (not to exceed 4 pages for each speaker):<br />
Date Availability: Please select ALL dates you are available to present.<br />
Thursday, June 19, 2014 Friday, June 20, 2014 Saturday, June 21, 2014<br />
Comments:____________________________________________________________<br />
Membership:<br />
Please indicate membership of ADHA:<br />
Not an ADHA member<br />
Yes, ID# ___________(for each speaker)<br />
Travel/Hotel:<br />
The following is provided for all CLL speakers:<br />
• Air Fare to/from event (coach)<br />
• 1 night hotel accommodations<br />
• Ground Transportation (not to exceed $50 each way)<br />
Comments:____________________________________________________________<br />
Honorarium:<br />
In addition to travel and hotel, requested honorarium is $______<br />
Book Signing:<br />
If you are interested in having a table in the back of the course room in order to sell<br />
books/materials, ADHA will adjust your honorarium. Please indicate your intent:<br />
No, I do not want a table for book signing/sales of materials<br />
Yes, I want a table for book/material sales and agree my honorarium will be adjusted.<br />
Photo:<br />
I have included in my submission a high resolution jpeg photo for each speaker.<br />
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