Speaker Name

Email Address

CONTACT INFORMATION

Mailing address

Office Phone

Mobile Phone

Home Phone

Fax

Assistant's Name

Assistant's Phone

Assistant's Email Address

Please list how you wish to be listed in the program

BIO (List EXACTLY as you wish it printed in the Meeting Program.  Excerpts will be taken for your verbal introduction)

CME

I am seeking CME credit for this meeting 

I am NOT seeking CME credit for this meeting.

TRAVEL

I am driving to and from the hotel (skip ahead to ACCOMMODATIONS)

I am FLYING to and from the hotel (please complete Arrival/Departure info below)

 ARRIVAL

I DO / I DO NOT wish to be shuttled from the airport to the hotel

Airport      Airline

Arrival date      Flight Number      Arrival Time

DEPARTURE

I DO / I DO NOT wish to be shuttled from the airport to the hotel

Airport      Airline

Departure date      Flight Number      Departure Time

ACCOMMODATIONS

I have been told the FSO/HNS-FSFPRS will make my room reservation at the hotel. 

OR

I understand I will be making my own room reservation at the hotel. 

Please complete the following in either case,

I will be checking in on

I will be checking out on

GUESTS - Guest expenses are the responsibility of the speaker.  Please list the names of your guests while at the hotel (spouse, children/ages, relatives, guests, etc.)

Name , Relationship , Age (if under 18)

Name , Relationship , Age (if under 18)

Name , Relationship , Age (if under 18)

Name , Relationship , Age (if under 18)

Name , Relationship , Age (if under 18)

ACTIVITIES - sign me and/or my guests up for the following:

FRIDAY

Cocktail Reception - Friday, 6:00 - 7:30 p.m., number attending (Children's activities will be provided)

SATURDAY

Cocktail Reception, Al Fresco - Saturday, 6:00 - 7:30 p.m., number attending

EDUCATIONAL OBJECTIVES

The FSO/HNS - FSFPRS Education Committee has provided you with basic objectives for the topic(s) that you will be presenting. As an expert in the field however, please expand upon the provided objectives by completing this form.  Objectives are not expected to be exhaustive.  They should make clear the knowledge, skills or attitudes that will be gained by the participant. 

Title of Presentation 1: 

Upon completion of this lecture/workshop/panel, the participant should be able to:

1)

2)

3)

Title of Presentation 2: 

Upon completion of this lecture/workshop/panel, the participant should be able to:

1)

2)

3)

Title of Presentation 3: 

Upon completion of this lecture/workshop/panel, the participant should be able to:

1)

2)

3)

In an effort to focus our funding efforts, please assist us by listing companies that might find your topic(s) of interest and might want to support the meeting financially:

AUDIO VISUAL REQUIREMENTS - I will need the following equipment for my presentation(s):

LCD Projector/Wireless Remote/Laser Pointer

One 35mm slide projector

Two 35mm slide projectors

Video Player - 1/2" tape

Video Player - 3/4" tape

Overhead Projector

Whiteboard and markers, colors:

Flip chart and markers, colors:

Other AV needed:

I require only voice amplification OR  my presentation(s) will include sound beyond my oration.

I will be presenting via Microsoft Power Point and have NO integrated video in my presentation(s) (a laptop will be provided)

I will be presenting via Apple Keynote or other software (speaker must provide laptop AND LCD converter cable extension to run onsite)

I have integrated video into my presentation file (speaker must provide laptop AND LCD converter cable extension (if using a Mac) to run onsite)

HANDOUTS

It is highly encouraged that you supplement your presentation slides with supporting documents, articles, research results, etc.  In lieu of passing out printed handouts during the meeting, we will be mailing CDs with PDFs of the presentations and any additionally provided handouts to all interested attendees PRIOR to the meeting if we have them in hand by the deadline - NOVEMBER 1, 2008.

YES, I will provide handouts for the CD and understand that they will be given to attendees via CD.  PowerPoint slides will be included in PDF form, 6 slides per sheet, as would a physical handout be printed. 

Please read the following disclaimer and "sign" your name to agree with the statements.

The undersigned Faculty (the “Undersigned”) agrees to:

1.  Grant to the FSO/HNS and FSFPRS a nonexclusive, irrevocable worldwide license to reproduce my presentation for the attendees of this meeting. This license does not prohibit the Undersigned from using this presentation in the future for his/her own professional or personal work.

2.  Warrant and represent that, to the best of Undersigned’s knowledge, nothing in the presentation violates the personal rights of others (including, without limitation, any copyright or privacy rights), is factual and contains nothing libelous or otherwise unlawful.

3.  Warrant and represent that the presentation is the Undersigned’s own original work, that Undersigned has the   authority to enter into this agreement, and the Undersigned is the sole copyright holder or that has attained all necessary licenses from any persons or organizations whose material is included or used in the presentation.

4.  Indemnify and hold harmless FSO/HNS or FSFPRS from any claims for damages, costs or expenses arising from claims of copyright infringement resulting from the publication, sale, dissemination or distribution of any materials submitted and/or presented by the undersigned, either orally or in writing. The undersigned further agrees to indemnify FSO/HNS or FSFPRS against any liability from any statements, oral or written, made by the Undersigned during or after this presentation.

Entering your name in the following space acts as my signature and agreement to the above statement:

Select one option below:

I will mail a CD of my handouts to FSO/HNS - FSFPRS - 6134 Poplar Bluff Circle, Suite 101, Norcross, GA  30092.

I will email my handouts to maryann@theassociationcompany.com

NO, I will not be providing handouts for the CD.

I will provide a copies of my presentation in handout form for distribution to all attendees at the meeting. (70 copies)

FINAL PRESENTATION

In order to assure ACCME Standards are followed, a copy of your presentation must be sent for our CME Committee to review prior to the meeting.  Deadline - November 1, 2008.

PLEASE NOTE: AFFILIATIONS LISTED ON THE DISCLOSURE FORM MUST ALSO BE LISTED ON YOUR PRESENTATION, ON THE PAGE JUST AFTER THE TITLE PAGE, PER ACCREDITATION "FIRST SLIDE" POLICY.

I will mail a CD of my final presentation(s) to Maryann McGrail - FSO/HNS-FSFPRS - 6134 Poplar Bluff Circle, Suite 101, Norcross, GA  30092.

I will email my presentation(s) to maryann@theassociationcompany.com

FACULTY DISCLOSURE  See Faculty Disclosure Statements

Individuals need to disclose relationships with a commercial interest if both (a) the relationship is financial and occurred within the past 12 months and (b) the individual has the opportunity to affect the content of CME about the products or services of that commercial interest.

Financial relationships are those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities for which remuneration is received or expected. ACCME considers relationships of the person involved in the CME activity to include financial relationships of a spouse or partner. The ACCME has not set a minimum dollar amount for relationships to be significant. Inherent in any amount is the incentive to maintain or increase the value of the relationship.

Use the following categories to indicate the type of financial relationships you are disclosing either for yourself or for you immediate family as defined above.  If an individual is uncertain about what might constitute a potential financial conflict or interest they should err on the side of full disclosure.

Please select one of the following two options

I DO NOT have any financial relationship to disclose.

I have the following financial relationships to disclose:

Company/Organization:

    Code(s): C    E    L    O    P    S

    Code(s): C    E    L    O    P    S

    Code(s): C    E    L    O    P    S

    Code(s): C    E    L    O    P    S

    Code(s): C    E    L    O    P    S

    Code(s): C    E    L    O    P    S

    Code(s): C    E    L    O    P    S

    Code(s): C    E    L    O    P    S

I intend to reference unlabeled/unapproved uses of drugs or products in my presentation (specify drug(s) or product(s) by name for which the unlabeled use will be discussed.

I have read the Disclosure Requirements and to the best of my knowledge, the information provided on this form is true and correct and represents all items for disclosure.  I understand that failure to comply with the disclosure policy, when known and deliberate, may result in disqualification for two years in similar educational or related activities.  I agree to promptly notify the program directors is any of this information changes.

Entering your name in the following space acts as my signature and agreement to the above statement:

PLEASE NOTE: AFFILIATIONS LISTED ON THE DISCLOSURE FORM MUST ALSO BE LISTED ON YOUR PRESENTATION, ON THE PAGE JUST AFTER THE TITLE PAGE, PER ACCREDITATION "FIRST SLIDE" POLICY.