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2011 Participant Information Form

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									2011 Participant Information Form
Please email the completed form to Cindy Weber @ weber168@umn.edu. In addition, please
submit your photograph as a digital image attached to an email.

Please complete the following NELD Participant Information and return by November 19, 2010.


Name

Institution

Program Area

County/Campus/Department


Street Address


City

State

Zip

Work Phone

Cell Phone

E-mail
Dietary Restrictions?       Yes           No

If yes, explain:

International Travel Information:
(If you prefer to give this information via phone, please contact Cindy Weber @ 507-389-6975)

Name as it Appears on Passport

Passport #

Date of Birth
Biographical Sketch: Please describe your work experience, your present responsibilities, and
any personal information you would like to share (150 word max).

To paste text into box, use ‘Control V’

								
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