Conference Speaker Application

Conference 2026 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.

Address for payment*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Medical Specialty*

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*

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

Honorarium Option (Choose One)*

$400 Honorarium

Complimentary Event Registration

Please attach a Headshot

Drop files here or

Max. file size: 512 MB.

Disclosure Information

Click here to download a fillable PDF to the AAPA disclosure form

Please Upload AAPA Faculty Disclosure form here*

Max. file size: 512 MB.

As a prospective planner or faculty member, we would like to ask for your help in protecting our learning environment from industry influence. Please complete This form via the link:chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.aapa.org/wp-content/uploads/2017/03/Sample-Disclosure-Form.pdf . The ACCME Standards for Integrity and Independence require that we disqualify individuals who refuse to provide this information from involvement in the planning and implementation of accredited continuing education. Thank you for your diligence and assistance.

E-Signature

Type in Your Name*

Date*

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