Test Form Charter Oak Conference Speaker Submission Name - Please provide your full name and credentials(Required) First Last Credentials Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email(Required) To ensure communication, we recommend using a personal email, as some institutional servers may block our emails Phone(Required)Employer(Required)Specialty(Required)Exact title of your presentation(Required)Please provide 3 Learning Objectives for your presentation.(Required)This is required as part of the accreditation applicationPlease provide a short bio/introduction that we can use in our program materials and mobile app.(Required)Part II - Let's Get StartedIn the event your topic is selected, we ask that you fill out the information below now. This information will assist us in streamlining communications with you and allow us to plan more efficiently. 1) For our marketing, mobile app and social media purposes, please give us a brief summary of your presentation that is separate from your learning objectives.(Required)2) Are you submitting this topic to present Live or Pre-Recorded?(Required) Live Pre-Recorded (once your submission is accepted, we’ll follow up with all the details and requirements) 3) Schedule 1st Choice(Required) Sunday, March 22 Monday, March 23 Tuesday, March 24 Please Indicate the Date and Time you wish to present. Note: we make every effort to accommodate your request.3b) Schedule 1st Choice(Required) AM PM Please Indicate the Date and Time you wish to present. Note: we make every effort to accommodate your request.4) Schedule 2nd Choice(Required) Sunday, March 22 Monday, March 23 Tuesday, March 24 4b) Schedule 2nd Choice(Required) AM PM 5) Honorarium Selection:(Required) Honorarium $250 (Non-Negotiable) Hotel Reservation - Saturday, March 21 (Limited) Hotel Resevation - Sunday, March 22 Hotel Reservation - Monday, March 23 Please donate my honorarium to CTPAF in support of student scholarships Please choose one of the options below. Please note: Speakers provided by AAPA or another pre-accredited educational organization do not need to complete this, as payment is made directly by the contracting entity.6) Audio/Visual: To help us stay on schedule, we ask that you use our laptop, which will have your presentation preloaded. ConnAPA will have an A/V technician at all times during the conference to assist you if needed. If you have additional needs, requests, or specific instructions, please let us know. Also, please indicate if your presentation includes video content or requires audience polling through our mobile app.7) ConnAPA will make your slides available as a PDF to all registered attendees through our mobile app. Do you authorize us to share your slides as a reference for attendees? Yes No 8) Please upload a headshot or high-quality photo for our program.(Required)Accepted file types: jpg, jpeg, png, gif.Please refrain from using web cam photos or self portraits. Faculty Disclosure(Required)Max. file size: 200 MB.
