Request a Program Form

Please fill in your information

Title:

First Name:

Last Name:

Email:

Phone Number:

Course or Organization:

FAU Course Course Prefix: Course #:
Student Organization
Other:

Estimated Number of Attendees:

We need to receive your request 3 weeks in advance of your preferred date.

Program Date:

Month:

Day:

Year:

Building/Room #:

Start Time:

End Time:

Have you contacted a CDC staff member?:

If yes, who?

Please check any available equipment at your site:

Internet Connection
Laptop
LCD Projector
Overhead Projector
Screen

Please select one of the following Programs

Workshop:

Information Sessions:

5 Minute Overview of CDC Services
Information Tables
None