1. Name of sponsoring organization

2. Activity title

3. Type of activity (course, seminar, workshop, etc.)

4. Date(s) / time

5. Location (hotel / city)

6. Name and title of contact person

7. Name of OHBM member involved in planning (if applicable)

8. Target audience

9. Estimated attendance

10. Methods of promotion

11. Registration fee?  (Yes / No)

             Anticipated amount $

12. Activity supported by commercial firm(s)?  (Yes / No)

             If yes, give name(s) of firm(s)

NOTE:  OHBM policy requires that OHBM staff must be provided the opportunity to review drafts of publicity material prior to publication and distribution to ensure that names of commercial supporters are disclosed.

Return by March 15, 2004 via Internet or fax to:
Julie Ratzloff, fax: 952-545-6073