IMA Event Broadcast Request

This form is used to request the broadcast of an event nationally.

Submitter's Information
Host InfraGard Chapter*
Submitter's Name*
First Last
Email*
Phone*
Date and Time
Date and Time that you are conducting the webinar/event.
Webinar Date*
Date Format: MM slash DD slash YYYY
Time zone where webinar/event will be held?*
- Eastern
- Central
- Mountain
- Pacific
- Hawaii
Start Time*

: HH

MM
End Time*

: HH

MM
Topic
Webinar/Event Title*
Webinar/Event Description (200 words or less)*
Learning Outcomes/Objectives
These are required if you want to issue CPEs for this webinar. If so, provide 3 or more learning outcomes/learning objectives for the topic. (In the format of "Upon completion of this webinar, the attendee/student will be able to _____________" (Three learning objectives are required for ASIS CPE credit) Please note that if you want to offer CPE, your IMA needs to be the one to prepare and issue the certificate for this.
Presenter Information
Presenter #1 Name*
First Last
Presenter #1 Title and Company Name*
Presenter #1 Biography*
BIO: (Tell us briefly about the speaker. Occupation? Experience with topic? Any honors or distinctions? Recent work? Why are they wantingregistering to present?)*
Presenter #2 Name
First Last
Presenter #2 Title and Company Name
Presenter #2 Biography
BIO: (Tell us briefly about the speaker. Occupation? Experience with topic? Any honors or distinctions? Recent work? Why are they wantingregistering to present?)*
Presenter #3 Name
First Last
Presenter #3 Title and Company Name
Presenter #3 Biography
BIO: (Tell us briefly about the speaker. Occupation? Experience with topic? Any honors or distinctions? Recent work? Why are they wantingregistering to present?)*
Presenter #4 Name
First Last
Presenter #4 Title and Company Name
Presenter #4 Biography
BIO: (Tell us briefly about the speaker. Occupation? Experience with topic? Any honors or distinctions? Recent work? Why are they wantingregistering to present?)*
Who Should Attend
Describe who would benefit from attending this webinar, what job classifications, roles, sectors, etc.
Who Can Attend*
Open only to vetted InfraGard members
Open only to InfraGard members and their guests
Open to anyone
Select from below to indicate if this webinar is ONLY for InfraGard members, for InfraGard members and their specific guests, or if the webinar is open to anyone.
Provide a link for attendees to register for the webinar/event:*
Name and email address of person to contact with questions about this webinar/event*
Include here any other notes or information INMA would need to process this broadcast.
Other Information
Include here any other notes or information INMA would need to process this broadcast.
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IMA Event Broadcast Request

Submitter's Information

Date and Time

Topic

Presenter Information

InfraGard National Members Alliance