Speaker Form | Connecticut Academy of PAs

Upon clicking the Submit button below, your form and any files you attached will be sent to the ConnAPA office. You will receive a confirmation of receipt within 1-2 business days at the email address you provided. If we have any questions about the information, we will contact you. Further correspondence from you can be sent directly to: connapa@ssmgt.com

Thank you for your interest in participating in the educational needs of physician assistants.

Name*
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Title/Degree*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Speciality
Employer*
Job Title
Topic/Title of Presentation
Learning Objectives*
Please submit a minimum of 3 objectives
Brief Bio. Please do not upload your CV.
Professional Quality Headshot
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