Program/Project Proposal Submission Form

I am an NLA Member
Contact Information
First Name*:
Last Name*:
Suffix:
Address:
City:
State:
Zip:
Phone:
Fax:
Email*:

Type of Program¹

Committee
Writing Group
Other Project/Program
Describe "Other" (if applicable):
Program Details
Title:
Date Due/Date of Program:

Primary Contact (if different from above):

First Name:
Last Name:
Address:
City:
State:
Zip:
Phone:
Fax:
Email:

Proposed Volunteers:

Chair(s):
Volunteers:
Additional Volunteers:
Additional Information
Estimated Budget Impact: (if known)
Estimated Cost to Participate: (if known)
Estimated NLA Staff Required: (if known)
Brief Summary of Program/Project:
What are the Deliverables of the Program/Project?
What is the Desired Outcome of the Program/Project?

¹ To submit a proposal for a CME program or project or if you are seeking NLA Endorsement of a program or project, you must complete the NLA Application for Endorsement of Program. The form is located at www.lipid.org/education/endorsement.

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Program/Project Proposal Submission Form