Add New Record in mysqli Database

Biographical Information
First Name
Last Name
Full Mailing Address
Contact E-Mail
Contact Phone
xxx-xxx-xxxx
Contact Cell
xxx-xxx-xxxx
Club Name or Organization
Designation
Brief Biography:
Presentation Information
1. Select the developmental track which your presentation represents:
Personal Development
Professional Development
Club Development
2. Title of your presentation and anticipated length (45 min minimum - 50 min maximum)
3. Have you presented this workshop before? If yes, when and where?
4. Briefly describe your presentation (outline and benefits of attending your workshop)
Purpose of workshop:
Further goals of this workshop are to:
Benefits:
This workshop fits into the theme by:
5. Explain why you are qualified to present this workshop.
6. Audio/Visual/Equipment Requirements. Please tell us your needs (check all that apply) :

Projector/Screen
Flip Chart/Easel/Markers
Additional Requirements:

You will be responsible for providing additional equipment and supplies, such as laptops, handouts or other workshop materials. The Education Co-Chairs must be informed of any changes in your Audio/Visual requirements no later than two weeks prior to the conference. Last minute changes will not be accommodated.



Charter DateClub NameAnniversary
February 1st 1964Bergen ToastmastersCelebrating 55 Year Anniversary