AND WHAT IF YOUR TESTIMONIAL COULD CHANGE SOMEONE’S LIFE?
THIS ACTIVITY WILL TAKE PLACE FROM MARCH 1 TO APRIL 30, 2012

REGISTRATION FORM FOR SPEAKER

Confirmation will be sent by email.

Information:
Julie Desjardins
jdesjardins@ccmm.qc.ca
Telephone: 514 871-4000, ext. 4047

Last name*:
First name*:
Function/Title:
Company or organization*:
Address:		Floor / Suite:
City:		Postal code:
Telephone*: Example: 514 871-4000		Ext.:
Fax: Example: 514 871-4000
E-mail*:
If you want to visit your old high school, enter its name:

Language of the presentation:	French English French or English
Regions you are willing to travel to (you can choose more than one region)::
	Montréal Island South Shore North Shore Outside Montréal Island (East) Outside Montréal Island (West)
Please indicate three dates and AM or PM, according to availabilities (between March 1st and April 30th).
	1. (Day/Month) AM PM
	2. (Day/Month) AM PM
	3. (Day/Month) AM PM
Are you available for more than one testimonial?
	Yes No (if yes how many?)
Are your dates flexible?
	Yes No
What school subjects do you use in your day-to-day tasks*?
	French Math English Geography History and politics Art Physical education and health education Ethics Science Current affairs Economics Other
What discipline did you study?

Did you ever think about abandoning your studies?
	Yes No
How did you hear about Operation Back to School?
	The Board of Trade’s Website Letter Email Colleague or friend Other
Comments and details about the presentation:

*: obligatory

Improve your public speaking skills with a training session led by Mr. Carol Allain on February 14 (in French only).