PRS Speaker Form

PRS Annual Meeting
Speaker Agreement
Speaker Name
1
Lecture(s)
I preferred to be contacted by:
Other
My office contact person:
Office phone number
Cell phone number (for emergency onsite contact only)
Email
Mailing address
Please provide your name with professional title(s) and position(s) as it will appear in the program brochure
Upload of Required Documents
This form cannot be submitted without these files.
Complete your CME Speaker Agreement Now
Upload your CME speaker agreement.
Upload a File
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Complete your Photo/Video Release Now
Upload your photo/video release form.
Upload a File
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Complete your Website Agreement Now
Upload your website agreement.
Upload a File
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Complete your W-9 Now
Upload your completed W-9.
Upload a File
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Complete your CME Speaker Disclosure Now
Upload your biography (not CV). Maximum word count of 300.
Upload a File
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Upload your head shot to be used for meeting marketing.
Hotel Accommodations
The Sheraton Harrisburg/Hershey, Harrisburg, PA
Will you require overnight accommodations?
If yes, date of arrival.
If yes, date of departure.
Spouse/Guest
ADA requirement (if appicable)
Terms & Conditions
I agree to have my presentation submitted by Friday, August 11, 2017. If I do not feel I will be able to meet this deadline I will contact PRS staff as soon as possible to coordinate late submission. I also understand that if I have not submitted my presentation by Friday, August 11th, handouts for my lecture(s) may not be provided to attendees.
If I am unable to present, I will make a "best attempt" to find a comparable replacement and will notify PRS staff immediately upon discovering a conflict with my presentation date or time.
Signature
Clear
Should be Empty:

PRS Annual Meeting