Name:

Position/Title:

Courses taught (if applicable)

Academic degree(s)

Other study

Areas of expertise

Have any of your peers considered you an expert or called upon you to speak on this subject?

Books published (if applicable)

Do you have a lecture that would make a good public speech? If so, what is the title and/or subject matter?

Would you feel comfortable and willing to speak with reporters?

Yes No

Do you have any additional comments?