Below is the application to be an instructor at the Goldfarb Foundation's 2017 Clinical Conference.  All details for the event are included in this letter, please read the letter in it's entirety before completing the application.  If you encounter issues with the application, contact Lara Beer-Caulfield.

All applications submitted by January 9, 2017 at 9;00 am will be reviewed at the Foundation's January Planning Meeting.  Applications received after January 9 will be reviewed on an as needed basis.
 
 

CONTACT INFORMATION



CREDENTIALS & MEMBERSHIP

The Foundation requires all of it's DPM speakers to be active (dues paying) APMA & component society members. Are you currently an APMA member?


Select below which organization(s) you are a MEMBER of (membership has no bearing on your application and whether you are selected to lecture at a meeting).





Select below which organization(s) you are credentialed by. Certification is not a requirement for lecturing.






FINANCIAL DISCLOSURES

Disclosures: Select below if you have any disclosures to make, this information will be reviewed by the planning committee.

If applicable, check which type of disclosure you need to make and then list the relevant names of the companies/organizations.
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LECTURE PREFERENCES & INFORMATION

Select your preferred speaking day/timeframe





Complete the information below pertaining to the lecture you would like to present.  You must enter the title and description of at least one lecture and are welcome to complete the information for a second lecture.
Topic area lecture #1 will cover











Enter information relevant to your lecture-objectives, purpose, and what an attendee at the lecture can take away in implement in their practice.
Approximate length of lecture #1



Is this topic surgical or non-surgical in nature?

Topic area lecture #2 will cover











Enter information relevant to your lecture-objectives, purpose, and what an attendee at the lecture can take away in implement in their practice.
Approximate length of lecture #2



Is this topic surgical or non-surgical in nature?



CV UPLOAD

CV Upload
Upload a copy of your CV for our review. PDF or Word documents only.

ATTESTATION & SUBMISSION

By checking "yes" below and entering your initials, you are signing this application and attesting that you are the speaker applying and not a third party organization submitting the information on behalf of another person.
Select yes below to agree to the terms as stated above.
By entering your name, it is equivalent to your signature in agreeing to the above terms.
Click the "Submit" button below to send your application.
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