Open House Academic Registration Form

Department Name: *

Representative #1 Designation:

Dr.

Mr.

Mrs.

Ms.

Representative #1 Name: *

Representative #1 Academic Title (for name tag): *

Representative #1 Email:*

Representative #2 Designation:

Dr.

Mr.

Mrs.

Ms.

Representative #2 Name:

Representative #2 Academic Title (for name tag):

Representative #2 Email:

Representative #3 Designation:

Dr.

Mr.

Mrs.

Ms.

Representative #3 Name:

Representative #3 Academic Title (for name tag):

Representative #3 Email:

Representative #4 Designation:

Dr.

Mr.

Mrs.

Ms.

Representative #4 Name:

Representative #4 Academic Title (for name tag):

Representative #4 Email:

Confirmation Details

Number of Tables Requested (Max of 3):

1

2

3

If you are requesting multiple tables, please indicate which departments or majors will be represented at each table:

Number of chairs needed:

Are outlets needed for the display?