Conference Speaker Application

Conference 2024 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 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

Unsure

Preferred Speaking Date/Time - 1st Choice*

PA Moms will try to accommodate slots based in the order applications are submitted.

Preferred Speaking Date/Time - 2nd Choice*

Honorarium Option*

$400 Honorarium

Complimentary Event Registration

Disclosure Information

Faculty Disclosure Form

A 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?*

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-Signature

Type in Your Name*

Date*

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