Community of Interest Webinar Request Form

Submit Your Webinar Request

Sponsoring COI

Point of Contact (POC) Please include the name and email(Required)

POC Email

Originator (if different from the POC) Please include the name and email

Please enter the date & time (including time zone) for your webinar(Required)

Please enter the date & time (including time zone) for your Dry Run (practice, communication check, etc.) session(Required)

Webinar Title (10 words or less)(Required)

Webinar Description (200 words or less)(Required)

Name(Required)

First Last

Speaker 1 Title(Required)

Speaker 1 Bio

Speaker 1 Photo (if you do not have photos for all speakers, we will not publish photos)(Required)

Accepted file types: jpg, jpeg, png, gif.

Speaker 1 Organization

Speaker 1 E-mail:

Speaker 2 Full Name

First Last

Speaker 2 Title

Speaker 2 Bio

Speaker 2 Photo

Accepted file types: jpg, jpeg, png, gif.

Speaker 2 Organization

Speaker 2 Email

Speaker 3 Full Name

First Last

Speaker 3 Title

Speaker 3 Bio

Speaker 3 Photo

Accepted file types: jpg, jpeg, png, gif.

Speaker 3 Organization

Speaker 3 Email

Moderator Full Name

First Last

Moderator Title

Moderator Bio

Moderator Photo

Accepted file types: jpg, jpeg, png, gif.

Moderator Organization

Moderator Email

Request COI notification email blast?

Yes

If yes, which COI(s) should be notified?

Text of requested email blast:

PDH Offered

Yes

PDH Form

Upload Form

Max. file size: 20 MB.

Learning Objectives (3-5 required for PDH, 4 required for AIA

Is there anything else beyond this form that we should know about your webinar?

Yes

If the answer to the above question is yes. Tell us more about your webinar

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