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Download SPEAKER FORM here. This form may be duplicated. Complete ONE form for EACH instructor (DO NOT SEND CV). Please print.
SPEAKER FORM
(Biographical Data and Financial Interest Disclosure)
COURSE TITLE:
PROGRAM TITLE/DATE:
NAME:
Mailing Address:
Telephone:
Email:
EMPLOYER:
Present Position:
PROFESSIONAL LICENSE OR CERTIFICATIONS (Check all that apply)
MD DO OD COA COT COMT ROUB CDOS CCOA
RN LPN/LVN CRNO CRA CO OC(C) ABO NCLE Other:_________________
EDUCATION POST HIGH SCHOOL: (Include basic preparation through highest degree held.)
DEGREE INSTITUTION NAME, CITY, STATE MAJOR AREA OF STUDY YEAR DEGREE AWARDED
1.
2.
3.
CURRENT AREA(S) OF SPECIALIZATION OR CONCENTRATION (Check all that apply)
Administration Education Neuro-ophthalmology Refractive Surgery
Cataracts General ophthalmology Pediatrics/strabismus Research Other _____________________
Cornea Glaucoma Plastics Retina _____________________
BIOGRAPHY: Briey describe your professional experience, area(s) of expertise, and any certications, including publications,
which qualify you to teach this course.
(Do not send CV)
CODE OF CONDUCT AND RESPONSIBILITY
Speakers have an obligation to attendees to provide the highest level of relevant education/learning materials and not their own personal
beliefs or philosophies. Speakers are encouraged to acknowledge the fact that the audience will be comprised of all races, ages, genders,
disabilities, and political aliations. Every attendee deserves a safe and comfortable learning environment free from any sexist or discriminatory
innuendos or language.
FINANCIAL INTEREST DISCLOSURE
For the purpose of this Financial Interest Disclosure, “Designated Company” means an entity related directly or indirectly to the manufacture or
distribution of lenses, pharmaceuticals, medical devices and instruments, vision care products, or services commonly utilized by ophthalmologists.
Check all boxes that apply and sign below.
Yes No
I, or a member of my family, my professional partnership or corporation, my employer, or co-instructor(s)/co-author(s), currently
or within the preceding twelve (12) months have had a nancial interest in Designated Company, a nancial relationship, advisory
capacity with any Designated Company, or entity related to my presentation, poster, or submitted manuscript.
Complete the following if applicable:
Stock shareholder
Company Name:
Consultant, advisor, or employee (compensated or non-compensated)/
Participated as a member of an advisory panel
Company Name:
Educational grant or research funds
Company Name:
Received free/discounted products or services
Company Name:
Received travel stipend or honorarium
Company Name:
Corporate sponsor
Company Name:
SIGNATURE OF INSTRUCTOR
I have read, understand, and agree to comply with the above statement and to the best of my ability, agree to be bound
by the “Speaker Code of Conduct and Responsibility.” I verify that the content within this document is valid and factual.
Date: ________________________ Signature by Mail or Fax: X _______________________________________________________________________________
or
Date: ________________________ Signature by Email:
This serves as an official signature of authentication
for all claims and information included in this form.
THIS FORM REQUIRED
WRITEABLE PDF
