Planner Biography Form

Title of CE Program*

Title of Committee

Planner Name, Credentials*

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

Planner Title:*

Planner Employer:*

Planner Email Address:*

example@example.com

Planner Telephone:*

Please enter a valid phone number.

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
Publications and presentations
Committees and organizations with which you’ve served
Awards
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. Dr. Brown is heavily involved with xx research initiatives and has published in xx journals. She is also affiliated with the xx school of pharmacy, precpeting students."

Please provide your biosketch in the box 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 funding is available:*

I am seeking assistance with travel expenses.I wish to decline financial assistance for travel and accommodations.

Do you wish to accept or decline your honorarium?*

AcceptDecline

You may access a blank W9 here.

Please complete and upload in the box below.

File Upload - CV and W-9

Photo Upload - Headshot