Speaker Interest Form

Speaker Interest Form

Please complete the form below to submit your speaker profile to the ACOEP CME Committee.
Name*

First NameLast NameDegree
Email*
example@example.com
Cell Phone*
Please enter a valid phone number.
Location*

Street Address

Street Address Line 2

CityState

Zip Code
Current Position*
Website (if any)
Degrees
Biography
Topics you are interested in presenting
Past Talks
Suggested Length

30 minutes60 minutesOther (lab, workshop, etc.)
From the organizations below, select those where you have spoken at one of their events. (check all that apply)

ACOEP (American College of Osteopathic Emergency Physicians)AAEM (American Academy of Emergency Medicine)ACEP (American College of Emergency Physicians)CORD (Council of Residency Directors in Emergency Medicine)EMRA (Emergency Medicine Residents Association)SAEM (Society for Academic Emergency Medicine)Other
Photo & CV*

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