Call for Presentations form 1Speaker Information2Presentation Information3Travel and Honorarium We welcome multiple presentation proposals but please complete one (1) form for each proposal.AARC membership numberName* First Last Professional Credentials RRT CRT NPS ACCS SDS RPFT CPFT RPSGT MD DO RN Other Education Credentials BS BA MS MA MBA M.Ed. MPH MHA EdD PhD Other Other Credentials This field is for special or educational credentials you would like on your name badge.Company / Organization* Title or Position* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Please provide a contact method. If you provide your cell phone, we may contact you to confirm you have arrived and prepared for your presentation.Email* Business PhoneCell Phone Presentation Title* Please provide at least one (1) overall objective for your presentation*Required for purposes of the CRCE application.A brief speaker introductory statement or biography*Used for podium introduction.Which day do you prefer to present?*The education committee has final control over lecture schedules. Wednesday Thursday Friday No preference Any conflict of interest to disclose?*Required for purposes of the CRCE application. No Yes Identify your conflict(s) of interest.*Please include all conflict(s) of interest and include the statement on your presentation.Is the presentation being sponsored by an organization other than the NJSRC?* No Yes Name sponsor* Please indicate any special needs for audiovisual equipment at the conference*Note: A PC laptop is standard with LCD projector connection at the lectern. Please provide your own projector adaptors if you are using your own PC or Apple (Mac) device. None Yes Special A/V needs* I will send my presentation materials via email prior to the conference.* No Yes Public posting of presentation material* Presentation materials MAY be posted on the Solutions X2 website after the conference. Presentation materials MAY NOT be posted on the Solutions X2 website after the conference. The NJSRC will provide all speakers will complementary lodging and meals during the conference and sponsored events. The NJSRC may provide non-sponsored speakers with a speaking honorarium. Travel expenses will be considered for out-of-state, non-sponsored speakers to be approved by the NJSRC Board.I would like to request Lodging Honorarium Both No speaker expenses I would like to request lodging forWe will provide lodging for one night related to your speaking but will book an additional night if you request. Wednesday night Thursday night Both nights No lodging requested I would like to request an honorarium for Any additional requestsProgram Integrity and Honorarium Statement*Requires full scroll to confirm choice.Program Integrity To ensure that all educational activities are free from bias, all presenters must declare vested interests. In the event that any form of commercial support is provided for an educational activity, the course sponsor will maintain control of the educational content and disclose to the learners all financial relationships or lack of, between the commercial supporter and the provider or presenters. Funds from a commercial source will be in the form of an unrestricted educational grant to the provider of the educational activity and must be acknowledged in printed material and brochures. Learners must be made aware of the nature of commercial support of all educational sessions. Educational activities that present research conducted by commercial companies will be designed and presented with scientific objectivity. Learners will be informed of any off-label use of a commercial product that is presented in educational activities. Off-label use refers to using a pharmaceutical agent for a purpose other than the purpose for which it was approved by the FDA. The approval status for an educational activity granted by the AARC does not expressly or implicitly confer AARC endorsement of the activity’s content. Honorarium This does not imply guaranteed reimbursement of any requested fees. While you may request a specific category for speaking engagement, the committee reserves the right to assign the speakers to categories as needed. I agree to the Program Integrity and Honorarium statement. Presentation proposals close on August 1. Speakers will be notified of selection by September 1.CommentsThis field is for validation purposes and should be left unchanged.