ELECTIVE WORKSHOP
SPEAKER APPLICATION FORM

ACFW 2013 NATIONAL CONFERENCE

DEADLINE TO APPLY: Monday, December 10, 2012

Privacy Statement: Please note, all personally identifying information collected will only be used within our organization

Name

First Name

Last Name

Psuedonym (if applicable)

Are you currently a member of ACFW? Yes No

Contact Info

Address

City

State

ZIP code

Country

Daytime Phone Number (Please include country and area code as applicable)

Email Address

Workshop

Workshop Title

List of speakers if more than one:

	First Name	Last Name
Speaker 1
Speaker 2
Speaker 3
Speaker 4
Speaker 5
Speaker 6

Speaker bio: (not to exceed 300 words)

One-sentence summary of your workshop

My workshop would best be categorized as (as indicated on the previous page)

Please list one place where you have taught fiction before (a local writer's group, for instance). Or if this is your first time to present a topic, please tell us that, too.

Workshop proposal outline: (up to 300 words)

Attach Copies of Handouts (required)

Please be sure your name and Workshop title appear in the upper left hand corner of each page you submit. Document(s) MUST be named with your proposed Workshop title and last name. EX: WriteTight1_SMITH.doc, WriteTight2JONES.doc, etc. -- use no spaces or punctuation in the document name other than an underscore ( _ ) or a hyphen ( - ) Attached files can be no larger than 500 kilobytes (512,000 bytes or .48828 megabytes) - only .doc (MSWord), .rtf (Rich Text Format), .wpd (Word Perfect), .pdf (Adobe), .xls (MSExcel) and .txt (Plain Text) file types are allowed.

Authorization for Media Reproduction

In the even your proposal is accepted, your Workshop presentation will be recorded and duplicated for distribution (in either audio or video format, or both). All costs for media reproduction will be covered by ACFW and all proceeds from the sale of the distribution media will be the property of ACFW. Please acknowledge that you have read, understand and consent to release such authorization by placing a checkmark in the box below.

I AUTHORIZE media recording and duplication (in either audio or video format, or both) of my presenation under the terms that all costs for recording will be covered by ACFW and all proceeds from the sale of the distribution media will be the property of ACFW. Because of ACFW's contract with the hotel and recording companies, I acknowledge and agree that all recording and/or videotaping is only allowed by ACFW or ACFW's contracted recording company.

ELECTIVE WORKSHOPSPEAKER APPLICATION FORM

ACFW 2013 NATIONAL CONFERENCE

DEADLINE TO APPLY: Monday, December 10, 2012

ELECTIVE WORKSHOP
SPEAKER APPLICATION FORM