LA-ACS Speaker Bureau
Interest Form
About You
Name
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First Name
Middle Name
Last Name
Suffix
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MD
DO
FACS
Other
Member Status
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Fellow
Associate Member
Affiliate Member
Senior Member
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Practice Type
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Academic
Private Practice
Community Hospital Employed
Mixed Model
Institution/Practice Name
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Your title
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Email
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example@example.com
Phone Number
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Office Contact
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Name
First Name
Last Name
Email
example@example.com
Phone Number
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Your Discipline
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*
General Surgery
Trauma/Critical Care
Breast Surgery
Vascular Surgery
Transplant Surgery
Thoracic Surgery
Cardiac Surgery
Otorhinolaryngology
Orthopedic Surgery
Urology
Pediatric Surgery
Colorectal Surgery
Surgical Oncology
Plastic Surgery
Minimally Invasive/Bariatric
Other
About Your Presentation(s)
How many presentations are you submitting?
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One
Two
Presentation Title
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Presentation Summary for Marketing Materials
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Objective(s)
*
Type Here
Objective #1
Objective #2
Presentation Title #2
*
Presentation Summary for Marketing Materials #2
*
Objective(s) Presentation #2
*
Type Here
Objective #1
Objective #2
Marketing Materials
Short Bio
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