| First Name:
|
|
| Last Name:
|
|
| Home Address:
|
|
| City:
|
|
| State:
|
|
| Zip Code:
|
|
| Home Phone:
|
|
| Personal Cell:
|
|
| Personal Email:
|
|
|
| Hostos Degree:
|
|
| Year of Graduation:
|
|
|
| Bachelor College Name: |
|
| Bachelor Degree: |
|
| Year of Graduation: |
|
|
| Master College Name: |
|
| Masters Degree: |
|
| Year of Graduation: |
|
|
| Doctoral College Name: |
|
| Doctoral Degree: |
|
| Year of Graduation: |
|
|
| Employer Name: |
|
| Job Title: |
|
| Work Phone: |
|
| Work Email: |
|
| Work Cell: |
|
| May we contact you at work? |
|
|
Please specify what your time commitment would be and with what frequency:
Please check all appropriate boxes
|
|
|
Other Frequency:
|
|
|
In what timeframes would you be available to give presentations?
Please check all appropriate boxes
|
|
|
Other Timeframe:
|
|
|
What is your area(s) of expertise?
Please check all appropriate boxes
|
|
|
Other Area of Expertise:
|
|
| Bio:
|
|
|