Speakers' Bureau Application Form

 

  

Thank you for your interest in participating in the ACEP Speakers' Bureau.  Please complete the application form below as completely as possible.  All items marked with an asterisk (*) are required information.

You can use the 'Tab' key on your keyboard to move to move to the next field quickly and easily.
 

* Name:
 

* Member ID:
 

Cell Phone:
 

* Preferred Email:
 

* Business Name:
 

* Business Address:
 

* Business City:
 

Business State:
 

* Business Zip:
 

* Preferred Contact Phone:
 

Please include any relevant hospital, community and ACEP titles below. 
* Professional Title(s):
 

*Have you taken any of ACEP's media training courses offered during past conferences?
 

    

 If yes, please (if possible) indicate when :
 

*In the past 2 years, how often have you been asked to speak in a public forum (outside of any course lectures, etc.)?
 

    

 Please indicate previous public speaking engagements, and topics covered.
 

Please indicate topics you would like to speak  about for the options below.  If you would like to speak on any topics not included here, please select "Other" and specify your topic in the next question.
 
*Topics:
Please make at least 1 selections from the choices below. 
  
  
  
  
  
  
  
  
  
  
  
  
  
  

Other (specify below)
 

Please include any relevant information about your role or expertise that qualifies you to speak on these topics.
 

 Please read carefully and acknowledge below:Yes, I am interested in becoming part of ACEP's Speakers Bureau.  I understand that my name, state, e-mail address, bio and area(s) of expertise will be made publicly available by ACEP for the exclusive purposes of promoting the Spokespersons Bureau, and that interested organizations may contact me directly to request a speaking engagement. I understand that I may not solicit any fees or honorarium (An exception of reasonable travel expenses may be made where as agreed to by me and any interested parties).  In addition, I agree [to the best of my ability] to convey ACEP's messages in order to promote its goals and objectives, and to act in accordance with all terms as outlined in ACEP's membership requirements. 

*I have read and agree to the terms above:
 

    

      
 
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