Teaching Poster Proposal

Title of Course 
Name(s) 
Primary affiliation(s) 
  
Mailing address    
  Line 1 
  Line 2 
  Line 3 
City 
State/Province 
Zip/Postal Code 
Country 
Work phone 
Cell or Home phone 
E-mail address 
E-mail address confirmation 
Abstract for Course (150-250 words) 
Special needs (if any) 
Other comments (if any) 
Attach syllabus (.doc,.docx, and .pdf only)