ECU Brody School of Medicine Academic and Faculty Development: Workshop Registration Form

WORKSHOP REGISTRATION FORM

Please complete and submit the form below to register for a workshop offered by the Office of Academic and Faculty Development. Once you click Submit, you will receive an e-mail from us to confirm your participation.

Workshop Name:
Workshop Date:

First Name:
Last Name:
Gender:
	Provision of this information is voluntary. It will be used for non-discriminatory purposes such as determining how we might effectively meet the diverse needs of faculty.
SSN Last 4:
	You must provide the last four digits of your Social Security Number in order to obtain CME credits.
Degree:
Specify Other:
	Please specify your degree if not found on the selection list above.
ECU Health Sciences Affiliation:
Specify Other:
	Please specify your affiliation if not found on the selection list above.
Department:
Specify Other:
	Please specify your department if not found on the selection list above.
Academic Rank:
Specify Other:
	Please specify your academic rank if not found on the selection list above.
E-mail:

Office Address:

Daytime Phone:

Comments: