Leader Visit Request Form

Important

THIS FORM MUST BE COMPLETED AT THE TIME OF THE REQUEST. FOR ROTATION LEADER VISITS, CHAPTER SERVICES BUDGETS 1 HOTEL NIGHT FOR THE LEADER, & SHOULD THE CHAPTER EXCEED THE NUMBER OF NIGHTS ALLOWED, THEY ARE RESPONSIBLE FOR THE REMAINING NIGHTS & EXPENSES.
  • Visit Information



     
  • Request Primary and Alternate Leaders  (do not select the same leader more than once)


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  • Is the chapter interested in scheduling a residency visit in conjunction with this visit?

               
  • Is CME being offered through ACEP?

               
  • Meeting Information


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  • If hotel and meeting location are the same, please click yes or no below

               
  • Will chapter reserve a room for leader

           
  • Hotel Location






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  • Meeting Location






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  • Specific Presentation(s) Requested

    • Presentation #1(Required)


       [None] Select a Date Delete the Date







       
    • Presentation #2


       [None] Select a Date Delete the Date  

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    • Presentation #3


       [None] Select a Date Delete the Date  

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  • Will there be a chapter board meeting and/or dinner?


     
  • Chapter Contact Information






     

  • You may also download the PDF form by clicking the link below as an alternative Here  
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