General Competition Application Form
Applicant's Information
Name
*
First Name
Last Name
Degree
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Years of Training
*
Dates of Training
*
Institution Information
Institution Name
*
City
*
State
*
Please Select
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Program Director Name:
*
First Name
Last Name
Degree
Program Director Email:
*
example@example.com
Program Director Title:
*
Program Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Competition Choice
Please choose the competition that you are applying for – only one competition per project is accepted.
Competition:
*
Please Select
Clinical Pathological Case Competition (Fall 2025)
Oral Abstract Competition (Fall 2025)
CPC Competition Faculty Discussant Information (Fall)
**If applying to the CPC Competition, Faculty Discussant information must be listed below. This information will be used to send blinded case abstracts to the Discussant, so please ensure that this is the home address (not the hospital) and the home/cell phone (not the hospital).
Faculty Discussant Name
First Name
Last Name
Faculty Discussant Title
Faculty Discussant Degree
Faculty Discussant Phone Number (Home/Cell)
Please enter a valid phone number.
Faculty Discussant Email
example@example.com
Faculty Discussant Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Project Information
Project Title
*
Project Authors
*
(list all authors and applicable titles such as DO, MD, RN, etc. Principle Investigator should be listed last)
Official Presenter(s)
*
Upload your Files
Submissions MUST be in the format as outlined in the
Competition Guidelines on the website
.
Competition File Upload
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AUTHORSHIP All persons meeting authorship criteria are listed as authors, and will certify that they have participated sufficiently in the work to take public responsibility for its content, including participation in the concept, design, analysis, writing, or revision of the manuscript. Furthermore, each author certifies that this material or similar material has not been and will not be submitted to any other publication before its appearance at the next national meeting of the American College of Osteopathic Emergency Physicians (ACOEP) without its prior, written approval. If this study has been or will be presented at any other national meeting, indicate the date of the meeting on a separate cover page. CONFLICT OF INTEREST I certify that any affiliations with or involvement in any organization or entity with any financial interest in the subject matter or materials discussed in this manuscript are disclosed below or in the cover letter. If none, state “none” below. INSTITUTIONAL REVIEW BOARD APPROVAL (If applicable) An institution’s human or animal subject review committee must approve all studies involving human or animal subjects. If your institution’s ethical research protocols exempt your study from such approval, state below. To maintain blinded peer review, do not include the name of the institution when identifying the review committee in the Abstract. Institutional review board approval or exemption has been completed. This will verify that I am the primary author of the project named below and provide this paper as an entry into chosen competition. I swear and attest to receiving the permission of my program director and the all other authors of the research I am submitting. Check one option below. This check box will serve as an electronic signature.
I am the primary author of the project and I will agree to the publication of the project.
I am the primary author of the project and I will abstain from the publication of the project.
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