CE Event Request Form

Thanks for providing the following information. If you have questions, please feel free to email janis.ellington@summitbhc.com.

My Name

My Email

Title of CE Presentation

Brief Summary of Presentation

This needs to be 3 to 5 sentences long in paragraph format. No bullets please.

Learning Objective #1

Three Objectives Required

Learning Objective #2

Three Objectives Required

Learning Objective #3

Three Objectives Required

Additional Learning Objectives

Add any additional Objectives here:

Presenter's Full Name

Presenter's Credentials

Presenter's Bio

5-6 sentences in paragraph form. No Bullets Please.

Date of Presentation

Start and End Time (Including Time Zone)

Virtual or In-Person Presentation

Location & Address (for In-Person Presentations)

Event Contact Person Name

Event Contact Person Phone Number

Event Contact Person Email

Host Facility/Facilities Name

Fee to Attend (if any)

Any other content you’d like included on promotion

Agenda

Please add the agenda for this event below. This would be a schedule of the program.

File Upload

You Must Upload:

Presenter's Resume

Presenter's Headshot

Host Facility Logo (or logos)

Drop your files here

Send me a copy of my responses