Speaking Faculty Information Form

Faculty Information Form
Full Name*
First NameLast Name
Title*
Credentials*
Clinical Affiliation*
Curriculum Vitae (CV)
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Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
Phone Number*
Area CodePhone Number
Fax Number
Area CodePhone Number
E-mail*

Lecture/Presentation Details
Title of Presentation*
Please upload your presentation material at the following link: MSDU 2017
Learning Objectives*
Use this space to list 2-4 objectives for your presentation
Presentation Summary*
Honorarium
$300/presentationDonate honorarium back to MSDU
Title of Presentation
Please upload your presentation material at the following link: MSDU 2017
Learning Objectives
Use this space to list 2-4 objectives for your presentation
Presentation Summary
Honorarium
$300/presentationDonate honorarium back to MSDU
Title of Presentation
Please upload your presentation material at the following link: MSDU 2017
Learning Objectives
Use this space to list 2-4 objectives for your presentation
Presentation Summary
Honorarium
$300/presentationDonate honorarium back to MSDU

Travel Arrangements
As a gesture of our gratitiude, the MSDU offers an honoraium along with the below accomodations. Please be sure to indicate all options you will need during the seminar. A Meeting Cordinator will follow up with you regarding further details.
Hotel Accomodations*
Friday, April 7thSaturday, April 8thBoth Friday and Saturday, April 7th - 9thOther
For our out-of-town speakers, we ask you make your own economy flight arrangements as soon as possible. These fees will be reimbursed by MSDU when you complete your expense report after the Seminar. We will arrange for a car service to pick you up at the airport.
Please note: All travel arrangements must be made prior to March 1^st2017 for MSDU to reimburse the costs.
Flight Arrival Information
Flight Departure Information
Should be Empty: