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Biographical Data Form
Please complete the form below and
include with the abstract submission form. All information will be kept
confidential.
Title of Abstract
______________________________________________________________
Name of Presenting Author
____________________________________________________
(Please use the name
of the author who will present if the abstract is accepted. All correspondence
will be sent to this person.)
Title
________________________________________________________________________
Organization
_________________________________________________________________
Address
____________________________________________________________________
City
__________________________________ State _________ ZIP Code_______________
Daytime Telephone
_________________________ Fax ______________________________
E-mail
______________________________________________________________________
Education (include basic preparation
through highest degree held)
Degree/Year Institution, City, State
Major Area of Study
________________
________________________ _______________________________
________________
________________________ _______________________________
________________
________________________ _______________________________
Professional experience (areas of
expertise and publications pertinent to this educational activity)
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
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