Speaker Name

Email Address

CONTACT INFORMATION

Mailing address

Phone

Mobile Phone

Fax

Type of Presentation:

    Resident (Fellow/Medical Student)

    ORAL (Physician)

Specialty:

    Facial Plastics and Reconstructive Surgery

    Otolaryngology

Presentation Title:

BIO (4 to 6 sentences written EXACTLY as you wish it printed in the Meeting Program. Excerpts will be taken for your verbal introduction)

Registration and Hotel Reservations

    I understand that I must register for the meeting and a hotel room. (Reservations will not be made based on this submission.)

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

LCD Projector/Wireless Remote/Laser Pointer

DVD Player

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 placing PDFs of the presentation onto a server for downloading by all interested attendees PRIOR to the meeting if we have them in by the deadline – October 25, 2010.

YES, I will provide handouts and understand that they will be placed on a server for downloading by meeting attendees. 

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.  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 email my handouts to smurton@cmemanage.com

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

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 - October 25, 2010.

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 email my presentation(s) to smurton@cmemanage.com