ACP AZ Speaker's Bureau Application

ACP Arizona: 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.
ZoomIn-person
If willing to present in person, how far are you willing to travel within the state of Arizona?
I am willing to speak pro bono.No speaking fee required, but travel expense reimbursement expected.Honorarium and travel expense reimbursement requested. ($500 max)Any honorarium be donated to the ACP Arizona chapter in my name.
YesNo
CV Upload:*

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ACP Arizona: Speaker's Bureau Application