ACP AZ Speaker's Bureau Application

The Arizona chapter of the American College of Physicians (ACP) invites internists and IM subspecialists to join our Speakers Bureau. In addition to the science of medicine, speaker expertise that can cover AI in medicine, informatics, health policy, end of life care, professionalism and ethics would be welcome. Providing statewide access to educational presentations that are current and evidence based, is the core mission of this program. If you have areas of expertise or would like to refer this opportunity to an expert colleague, please use this form to apply.

Applicant's Name

First NameLast NameCredentials

Current Institution or Practice:

Add subspeciality(ies) if applicable

Referred by

Preferred Email

example@example.com

Preferred Phone

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Title & Topics of Expertise

example@example.com

Please briefly share about your passion in your field/ expertise.

I am willing to present

I am willing to present:

If willing to present in person, how far are you willing to travel within the state of Arizona?

Honoraruim requested

I give permission to the ACP AZ to add my information to the online ACP AZ Speaker's Bureau. I also agree to use the 2 slides provided by the AZ Chapter in my presentation to inform the audience about the ACP, membership pathways and chapter engagement opportunities.

CV Upload:

ACP Arizona: Speaker's Bureau Application