Speaker Agreement

Last Name

First Name

Degree*

Academic-Medical School Affiliation/Title(s)*

Institutional-Hospital/Title(s)*

Division & Department*

Name of Hospital/Institution*

Address 1*

Address 2

City*

State/Province*

Zip/Postal Code*

Country*

Email*

Phone*

I accept the terms of the speaker agreement

I DO NOT HAVE ANY financial interest/s as identified below:

Research Grants

Advisory Role

Board Membership

Employment

Expert Testimony

Honoraria

Independent Contractor

Material Support

Management Position

Ownership Interests