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* 1. Program Name:

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* 2. Contact Person:

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* 3. Address:

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* 4. Phone:

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* 5. Email:

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* 6. Training Site Information (please complete if different than above)
Name of Training Site: 

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* 7. Address:

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* 8. Please give 3 possible dates that would work for your training: (Monday - Friday During the day 9-4pm, or Monday - Thursday Evening 6-9:30)

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* 9. Expected Number of Participants

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* 10. Desired Workshop Topics/ and or COK Area:

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* 11. Additional Information: request for specific trainer, issues to address during training, goal of training, deadline for completion, etc.

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* 12. Training Room Details: Is the room equipped with the following: Enough adult-sized chairs for all participants?

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* 13. Outlets for a laptop computer & projector?

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* 14. Projector screen or white wall for presentation?

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* 15. How did you hear about us? (Please select all that apply)

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