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Speaker Directory Inclusion Registration

(*) Required | New York ACEP Membership Required for Inclusion
First Name(*)
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Last Name(*)
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Other Degrees/Credentials
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Job Title
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Street Address
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Email Address(*)
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Honoraria Required
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Travel Expense Required
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What regions are you willing to travel to speak? (select all that apply)
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Area(s) of Interest
Speaking Topics Note: Hold the Ctrl key for multiple selections(*)

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Other (please specify)
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Photo must 500kb or below.

.pdf (Files)
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.pptx (Files)
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