FASD Center for Excellence - Speaker Request

Technical Assistance Request Form

Required items are marked with an asterisk (*).

I. Contact Information

*First Name: M.I.: *Last Name:

Position/Title:

Organization/Agency Name:

Email Address:

Address Type:

Business Address

Home Address

Address 1:

Address 2:

City:

*State: Zipcode:

*Country:

*Telephone (ex: xxx-xxx-xxxx): Fax:

How did you hear about us?:

II. General Information

Anticipated date of technical assistance:

Location of technical assistance:

Anticipated length of technical assistance:

III. Brief Description

Brief description of organization/agency/group requesting the technical assistance:

IV. Purpose

Purpose of the technical assistance or brief history of the problem:

V. Expected Outcomes

Expected outcomes of the technical assistance:

VI. How will the Learning be Incorporated

How will the Learning be Incorporated:

Do you anticipate needing some follow-up support from the Center:

Yes

Unknown

VIII. Additional Information

Additional Information: