PACEP Speaker Interest Form
For Medical Student Monthly Sessions
Name
*
First Name
Last Name
Current Employer
*
Title/Role
*
PACEP Role/Leadership Experience
*
Where did you complete your Residency?
*
Where did you complete your Medical School Training?
*
Lecture Topics/Discussion Subjects of Preference/Expertise
*
Please attach a current copy of your CV.
*
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Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Speaking Engagements/Previous Presentations
*
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