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Teacher Workshop Request Form Southeastern Nanotechnology Infrastructure Corridor senic


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Teacher Workshop Request Form

Southeastern Nanotechnology Infrastructure Corridor (SENIC

at the Institute for Electronics and Nanotechnology (IEN) at Georgia Tech

Thank you for your interest in having the Nanotechnology Research Center at Georgia Institute of Technology provide a workshop on nanotechnology education. To schedule a workshop (at IEN or at your site), please fill out the form below as completely as possible. We will contact you regarding your request in approximately one week.


Contact Person Information

First Name




Last Name




Job Title




School




Address 1




Address 2




City




State




Zip




Email Address




Work Phone




Work Fax

Cell Phone






Workshop Information





Preferred Date(s) for workshop

1st

2nd

3rd




If all dates listed above are unavailable, we will contact you for additional choices of dates.










Number of teachers (35 max)







Location of workshop

 Georgia Tech




 School




 Other (specify)







Grade Level(s) taught







Subject(s) taught



















Level of audience familiarity with nanotechnology

 not familiar

 some

 very familiar







Is Bus parking needed if coming to IEN?

 Yes

 No



Email or fax form to:



nancy.healy@ien.gatech.edu

Fax: 404-894-5142


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