Speaker Registration ACPNJ Speakers Bureau Status Pending Approved Type Presenter Faculty Option 3 Other Type Speaker Information Salutation * Dr. Mr. Mrs. Ms. Prof. First name * Last Name * Credentials Job Title System/Affiliation * Specialty (Please check all that apply) Internal Medicine Cardiology Geriatrics Hematology Hospital Infectious Disease Oncology Palliative Care / Hospice Public Health / Epidemiology Pulmonary Medicine Rheumatology Surgery Other Specialty (Please check all that apply) Email Address * Phone Number * Phone Number 2 Office Contact Person Warning: strpos() expects parameter 1 to be string, array given in /home/lutine2015/public_html/ctacp.org/wp-content/plugins/formidable/classes/models/fields/FrmFieldType.php on line 866 Warning: htmlentities() expects parameter 1 to be string, array given in /home/lutine2015/public_html/ctacp.org/wp-content/plugins/formidable/classes/models/fields/FrmFieldType.php on line 867 Address LinkedIn Profile Twitter Profile Facebook Profile Upload Curriculum Vitae Upload Headshot Speaker Bio (Please add a brief bio) ACPNJ Contact Name ACPNJ Contact Email ACPNJ Contact 2 Name ACPNJ Contact Email End Section Speaking Topics Speaking Topics by Subspecialty * Adolescent Medicine Allergy and Immunology Business and Practice Management Cardiology Endocrinology and Metabolic Diseases Gastroenterology Geriatrics and Palliative Care Hematology and Oncology Infectious Disease Nephrology Neurology Primary Care Public Health Pulmonology Rheumatology Sports Medicine Women's Health Other Speaking Topics by Subspecialty Specific Topics Upload Sample Presentation Link to Sample Presentation (If a sample presentation is online, please provide the web address) Upload LOA Link to LOA Attach W-9 Link to W-9 Upload Latest Disclosure Link to Latest Disclosure Anything to disclose Yes No End Section Honorarium (Staff only) Date Program ID Amount End Section Logistics How far will you travel to speak? * Anywhere Up to 50 miles 2 Hours or Less New Jersey only NJ/NYC/Eastern PA Will not travel OtherOther End Section
