NCCM Workshop / Leadership Bootcamp Request

Name of Requesting Organization:*

Name*

First Last

Address*

City Province

Work Phone*

Cell Phone

Email*

Choose Your Workshop*

Suggested Date of Workshop*

Time of Workshop*

: HH

MM

Location of Workshop*

City Province

Anticipated Size of Audience*

Age Group*

The Expected Audience:*

What are your requirements for this workshop?*

Is this workshop part of a larger event/conference*

If yes, Provide details on Program Segments and Speakers:

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