Speaker FormSpeaker Form Speaker InformationName (Please enter name as it should appear in the final program) * Name (Please enter name as it should appear in the final program) Name (Please enter name as it should appear in the final program) Name (Please enter name as it should appear in the final program) Choose one * MD, FACS MD OtherOther Institution/Practice * City * State * Email * Phone * Twitter Handle Speaker Bio: enter your bio here or attach below in doc, docx, or pdf format Upload your Bio Drop a file here or click to upload Choose File Maximum upload size: 268.44MB Headshot Drop a file here or click to upload Choose File Maximum upload size: 268.44MBShould we copy your administrative assistant on all communication? * Yes No Administrative Assistant * Administrative Assistant Email * Travel Plans Date of arrival, how many nights you are staying, etc. * Presentation Presentation Title * Session Summary * AV needs* Bring your own laptop, lapel mic, etc. * AR-ACS Disclosure FormIn accordance with ACCME regulations (ACCME Standard 3), the American College of Surgeons must ensure that anyone who is able to control the content of the activity has disclosed all financial relationships with any ineligible companies in the 24 months prior to their involvement in the educational activity.Ineligible Company: Companies that are ineligible to be accredited in the ACCME system (ineligible companies) are those whose primary business is producing, marketing, selling, reselling, or distributing healthcare products used by or on patients.Financial Relationships: Financial relationships are relevant if the following three conditions are met for the individual who will control content of the education: 1) a financial relationship, in any amount, exists between the person in control of content and an ineligible company; 2) the financial relationship existed in the last 24 months; 3) the content of the education is related to the products of an ineligible company with whom the person has a financial relationship.Name * Name Name Name ACS Member ID Number (if readily available) Email * All CME Planners and Speakers /Moderators/Discussants/Authors/Editors involved in the development and/or presentation of CME content must complete this form. This form must be updated whenever circumstances require. As relevant, all disclosure information for speakers must be revealed by a slide at the beginning of the presentation.Relationship * I am an owner, employee, or stockholder (not through a mutual fund or pension plan) of an ineligible company and there for am excluded from controlling content or participating as a planner or faculty in accredited education. For more information: ACCME Standard 3 I do not have personal financial relationships with any ineligible companies as defined above. I do have financial relationship(s) with ineligible companies as defined above. List the names of companies that you have a financial relationship with currently or have had in the last 24 months. * Explain what you received (i.e. salary, honorarium etc.). * Specify your role (i.e. consultant, board member, etc.) * I agree that I will not directly accept honoraria, travel expenses, in-kind contributions, or any other compensation from ineligible companies in connection with this activity (Support provided with a letter of agreement may be permissible).If any of the information reported above changes, I will notify AR-ACS immediately and update this form accordingly.By signing or typing my name below, I certify that I have identified and disclosed all financial relationships with any ineligible companies (in the last 24 months) and that all information provided herein is true and correct. Signature * Clear If you are human, leave this field blank. SubmitΔ
