ML18095A065

03/13-15/2018 RIC 2018 Session W20 NRC Form 1105 Golshan

ML18095A065
Person / Time
Issue date:	03/13/2018
From:	Russell Felts NRC/NRR/DRA
To:
Moulton C
References
Download: ML18095A065 (1)

Text

NRC FORM 1105 U.S. NUCLEAR REGULATORY COMMISSION (11-2017)

RIC SPEAKER CONFIRMATION FORM Session Information (Session Chair or Coordinator to Complete):

Session Date Time of Session (7:00, etc.) Session Number

Select Session Title Name of Session Chair Phone Number of Session Chair E-mail Address of Session Chair Name of Session Coordinator Phone Number of Session Coordinator E-mail Address of Session Coordinator Speaker Confirmation Information (Speaker to Complete):

Please TYPE or PRINT the requested information below. Please refrain from using abbreviations and ensure that acronyms are spelled out.

Applicable information will be used for the purpose of populating the online and printed conference program.

Speaker's Full Name Speaker's Full Position Title Speaker's Organization Name Speaker's Business Mailing Address (City, State & Zip code) Speaker's Business Telephone Number Speaker's Business E-mail Address Speaker Presentation Information (Speaker to Complete):

Proposed Presentation Title Speaker Biographical Information (Speaker to Complete):

Please provide a short biography in narrative form below. The information will be used for introductions at the conference and will be posted on the RIC public website.

Please submit the completed form, via e-mail, by the following date: Due Date:

NRC Form 1105 (11-2017) Page 1 of 1