Association of Fire Districts of the State of New York

Conference Speaker Application

This is the application for prospective speakers at conferences.

First Name *

Last Name *

Email *

Speakers Contact Address:

Phone #

Speaker Fees:

Position / Title

Fire Service / Related Affiliation

Proposed Class Name

Additional Instructors for this Class

Personal Narrative (Include: - Main points and goals of your session - Learning Objectives - Any Interactive Elements in the program) *

(Word limit: 300)

Presentation / Class Length (ie 90 Min class, Multiple Segments, etc) *

Intended Audience (Commissioners, Treasurers, Chief Officers, Admin Staff, Line Personnel, etc) *

Proposal Description (for Conference Materials / Brochure / Website) *

(Word limit: 50)

Biography for Presenter (To be published on website and in conference program materials) *

(Word limit: 100)

AV Equipment Needed?

Additional Speaker Info: Twitter

Additional Speaker Info: Facebook

Additional Speaker Info: LinkedIn

Additional Speaker Info: Tumblr

Additional Speaker Info: Website

References we can contact that have attended this or similar presentations that you have given

First Name

Last Name

Phone #

Affiliation

First Name

Last Name

Phone #

Affiliation