Quarterly CE Application Form Please enable JavaScript in your browser to complete this form.Title *Dr.Mr.Mrs.Ms. Speaker Name *FirstLastPreferred Name/Credentials *Additional Speaker (if appropriate)FirstLastPreferred Name/Credentials for additional speaker (if appropriate)AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Email *Biography *Please provide a brief biography or description of yourself. This will be used to introduce you as the speaker. Speaker Experience *Speaker Photo * Click or drag a file to this area to upload. Please upload your photo to be used on the conference website and platform.Title of Presentation *Course Synopsis *Short Description for handouts and brochure Course Objectives *Recommend at least 2-3 measurable objectives. For example, "By the end of this course, participants will be able to identify/describe/list..."Citations *My course is relevant to the following scope of OT practice *Service DeliveryProfessional IssuesFoundational KnowledgeYou may select more than one.Level of Presentation *NoviceIntermediateExpertPresentation Format *One hour presentationTwo hour presentationAudio Visual Requirements (select one): *I only need internet for my presentationNone Handout Materials *I will provide an electronic version of my handout material to OTAO no later than 3 weeks after the approval of the presentation by OTAO.In lieu of printed handouts, all handout materials will be emailed attendees to download in advance of the presentation.Scheduling Preferences * We will do our best to accommodate your availabilityAdditional InformationIf there is other information you would like OTAO Conference Committee to know, please type here. Submit Application Form FOR MORE INFORMATION: Occupational Therapy Association of OregonPhone: (971)266-4328 Email: info@otao.com