Conference 2025 Speaker Application "*" indicates required fields Name* First Last Title (i.e.:PA-C, MD, MS) ** Email Address* [email protected] | This is the email that will be used for conference communication.Medical Specialty* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Mobile Phone*Please enter a valid phone number.Speaker's Bio*Session Title* Session Description*Learning Objectives (please upload as 1.xxx, 2.xxx, etc)*Do you plan on your presentation containing any audio or videos?* Yes No Unsure Preferred Speaking Date/Time - 1st Choice*Friday, March 28 - Early MorningFriday, March 28 - Late MorningFriday, March 28 - Early AfternoonSaturday, March 29 - Early MorningSaturday, March 29- Late MorningFriday, March 29 - Early AfternoonPA Moms will try to accommodate slots based in the order applications are submitted.Preferred Speaking Date/Time - 2nd Choice*Friday, March 28 - Early MorningFriday, March 28 - Late MorningFriday, March 28 - Early AfternoonSaturday, March 29 - Early MorningSaturday, March 29 - Late MorningFriday, March 29 - Early AfternoonHonorarium Option* $400 Honorarium Complimentary Event Registration Please attach a Headshot Drop files here or Select files Max. file size: 512 MB. Disclosure InformationFaculty Disclosure FormA conflict of interest may exist if a faculty member of an educational activity, or spouse or partner of that person, has financial relationships with the grantor or any commercial interest(s) that may directly impact the content of the program. A financial relationship is defined as being a shareholder, consultant, grant recipient, research participant, employee, and/or recipient of other financial or material support. The participants in this CME activity must be made aware of any such financial relationship(s). All persons who may have control over the content must fully disclose any such financial relationship. This disclosure policy is intended to protect all parties involved from potential conflicts of interest that may arise. AAPA assumes responsibility for resolving these conflicts of interest. If you have no disclosures, please only complete the required items (designated with a red asterisk) below.Do you intend to discuss any unapproved / investigational use of a commercial product / device?* No Yes (Disclosure required) I will provide a balanced view of therapeutic options and will be entirely free of promotional bias* Yes No(Disclosure required) Enter your name (only if you have disclosure) First Last Enter your spouses name (only if relevant to a disclosure) First Last Please fill out the name of commercial interest (if applicable) to the Financial Relationships below.Honorarium Consultant Grants/Research Shareholder Other Financial or Material Support Speakers Bureau Employee Other Disclosure E-SignatureType in Your Name* Date* MM slash DD slash YYYY CAPTCHA