VAPAA Speaker Application Form

VAPAA Speaker Application Form
TELL US ABOUT YOU
Name*

First NameLast Name
Title (i.e.:PA-C, MD, MS)*
Non VA Email*
example@example.com | This is the email that will be used for conference communication.
Medical Specialty*
VA Clinic/Hospital Name*
Cell Phone Number*
Please enter a valid phone number.
Please upload a professional photo for us to use in the meeting application and for use in promotional materials about the conference.*

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Please upload Speaker's Resume/CV (without address or other contact information) as a PDF file. This will be used to determine eligibility and will be uploaded to the VAPAA Meeting Application.*

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Speaker's Bio*
Did someone specific recruit you to speak? If so, please list their name.

TELL US ABOUT YOUR PRESENTATION
Session Title*
Session Description*
Learning Objectives (please upload as 1.xxx, 2.xxx, etc)*
Please upload your presentation and any supplements you would like to include. This can be uploaded at a later date.

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Please choose your top three date/time slots. VAPAA will try to accommodate slots based in the order applications are submitted.
First Choice*
Second Choice*
Third Choice*

DISCLOSURE INFORMATION
Faculty Disclosure Form

A conflict of interest may exist if a faculty member of an educational activity, or spouse or partner of that person, has financial relationships with the grantor or any commercial interest(s) that may directly impact the content of the program. A financial relationship is defined as being a shareholder, consultant, grant recipient, research participant, employee, and/or recipient of other financial or material support. The participants in this CME activity must be made aware of any such financial relationship(s). All persons who may have control over the content must fully disclose any such financial relationship.

This disclosure policy is intended to protect all parties involved from potential conflicts of interest that may arise. AAPA assumes responsibility for resolving these conflicts of interest.

If you have no disclosures, please only complete the required items (designated with a red asterisk) below.
Do you intend to discuss any unapproved / investigational use of a commercial product / device?*

NoYes (Disclosure Required)
I will provide a balanced view of therapeutic options and will be entirely free of promotional bias*

YesNo (Disclosure Required)
Enter your name (only if you have disclosure)

First NameLast Name
Enter your spouses name (only if relevant to a disclosure)

First NameLast Name
Please fill out the name of commercial interest (if applicable) to the Financial Relationships below.
Honorarium
Consultant
Grants / Research Shareholder
Other Financial or Material Support
Speakers Bureau
Employee
Other Disclosure
E-Signature
Type in Your Name*
Today's Date*

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

VAPAA Speaker Application Form

TELL US ABOUT YOU

TELL US ABOUT YOUR PRESENTATION

Please choose your top three date/time slots. VAPAA will try to accommodate slots based in the order applications are submitted.

DISCLOSURE INFORMATION

Faculty Disclosure Form

E-Signature