Pittcon Conference & Expo Teacher Workshop Presenter Application

Presenter name*

Affiliation*

Email address*

Best phone number*

Address*

Street Address Address Line 2 City State ZIP Code

Workshop title*

Workshop description (please be as specific as possible)*

Content relevant for grade levels*

First choice - preferred day and time*

Second choice - preferred day and time*

Number of people required to present workshop? (includes instructor(s) and any helpers)*

Has this workshop ever been presented at Pittcon?*

If yes, list most recent years presented

Check all that apply*

If selecting "other", please list item(s)

If selecting 6 plug surge protectors, how many needed?

Will any toxic or ignitable chemicals be used?*

If "yes", please list explain

Select the type of room layout your workshop requires*

If you selected "other", please explain what kind of layout you need and why

Any special needs, considerations or instructions?

Teacher Workshop Presenter Application