IFSER 2017 Educator's Summit Speaker Information Form
The following information is being collected as part of the requirements for the ASRT sponsored CME credits we will provide at the Educator's Summit. Please fill all required fields. You may choose to upload a copy of your CV or resume to provide information needed for some of the fields as indicated below.
Email address
Last Name
Your answer
First Name
Your answer
Address, City, State and Zip
Your answer
Best Contact Phone Number
Your answer
Level of Education Completed
Speakers may choose to attach their CV/Resume to this email instead of filling out this portion.
Email Address
Your answer
Please list all relevant work experience.
Speakers may choose to attach their CV/Resume to this email instead of filling out this portion.
Your answer
Brief Outline of Lecture/Activity Content
Your answer
Please list all certifications/credentials you hold.
Speakers may choose to attach their CV/Resume to this email instead of filling out this portion.
Your answer
Lecture Objectives (please list 3)
Your answer
Lecture Title
Your answer
Which night(s) will you need hotel accommodations? (Check all that apply)
IFSER is prepared to pay for one night of hotel for our speakers. Additional nights may be reserved but will be the responsibility of the speaker.
Required
Which day would you prefer to speak?
Required
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