Speaker Bio & Activity Information Form

Today's Date*

Date

Title of CE Program*

Speaker Name, Credentials*

(Credentials, i.e. R.Ph. Pharm D., BCPS, etc.)

Speaker Position/Title:*

(Title, i.e. Clinical Oncology Pharmacist)

Speaker Employer:*

Speaker Email Address:*

example@example.com

Additional Email Address, if applicable

example@example.com

Assistant Name, if applicable

example@example.com

Assistant's Email, if applicable

example@example.com

Please note which communication(s) you would like your assistant to be copied on:

Email communications regarding my contract, potential payment/honoraria.Email communications regarding schedule, required documents, etc.All email communicationsNot applicable

Speaker MOBILE Telephone:*

Please enter a valid phone number for on-site communications.

CE Synergy is requesting a biosketch that may be used in written and electronic promotional materials, as well as during on-site introductions. When preparing your biosketch, please be sure to include the following pieces of information in the order in which they appear in the list below. Brevity is preferred for optimal conversion for a website and/or your verbal introduction.

Name
Current employment title and employer
Degree(s) obtained and conferring institution
Additional training and certifications
Additional noteworthy information

Example: "Jane Brown is a board certified oncology pharmacist practicing in malignant hematology at xx institution in city, state. She completed her PharmD at xx and her post-graduate residency training at xx."

Please provide your biosketch in the box provided below.*

The following data will be shared with attendees and sponsors: Name, Degree, Credentials; Title/Role; Employer; Email address. Please choose to opt-in or opt-out:*

Opt-inOpt-out

If there is available funding from grant support or other eligible resources, CE Synergy may offer to cover travel-related expenses. If funding is available, will you require assistance with travel-related expenses?*

Yes, I will need assistance with travel expenses.No, I will not need assistance with travel expenses.

If there is available funding from grant support or other eligible resources, you may be eligible for an honorarium for planning or speaking at this event. If an honorarium is offered, do you wish to accept or decline honorarium?*

Accept honorariumDecline honorarium

Please note that the 2024 version of the W9 form is required in order to receive honoraria. You may access the most recent version from 2024 of the W9 here.

Please complete and upload in the box below.

File Upload - CV and W-9*

Photo Upload - Headshot

Activity Information

Title of Educational Activity/Session:*

Activity Date:*

Date

Audience:*

PharmacistsTechniciansOther

Hours of Learning:

CPE Activity*

Knowledge-basedApplication-based

Will off-label uses be discussed during your presentation?*

YesNo

Learning Objectives for Pharmacists:
1.
2.
3.
4.
5.

I hereby give permission to CE Synergy, LLC. to share a copy of the handout created for this program (ie, PDF) with industry partners for their company’s internal use.