About SAGE

To provide us with information on your background, please take a few moments to fill out this brief profile form. You will be contacted at a later date to discuss your specific topic of interest.

First Name
Last Name
Title
Daytime Phone	( ) - ext
Alternate Phone	( ) - ext
Email
Employer
Home Mailing Address

City	State
Zip
I prefer to be contacted by Phone Email Either one

INDUSTRY (please check all that apply)

High Tech
         Hardware
         Software (e.g. database, software engineering, systems analyst)
         Database Systems
         Telecommunications
         Ecommerce/Internet (e.g. web design)
Life Sciences & Pharmaceuticals
Consulting
Science/Research (e.g. chemist, clinical laboratory, physicist)
Engineering
Math/Finance
Law
Medicine
Other

# of years in Industry

POSITION (please check all that apply)

Subject Matter Expert
Manager
Executive (SVP, EVP, VP)
Senior Executive (President, CEO, CFO, CIO)
Consultant
Owner
Other

WHAT TIME OF DAY WOULD YOU BE AVAILABLE AS A SPEAKER? (please check all that apply)

Mornings 9am - 12pm
Mid-Afternoon 12pm - 3pm
Afternoons 3pm - 5pm
Evenings 5pm - 8pm

WOULD YOU BE WILLING TO SPEAK (please check all that apply)

As part of a panel
Solo presentation

Name of Person who told you about the SAGE Speakers Bureau

Additional Comments

Biography (a brief description of your background - 1000 characters max.)

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