2017 The NECC Speaker Confirmation Form

Thank you for your commitment to speak at The NECC 12th Annual Summit. Please take a few moments to fill out the following questionnaire which will help assist in the planning of the conference and meeting the requirements of our accrediting bodies.

This information is important and included in the conference promotion, which directly effects the participant's evaluation of the educational activity.

Please note that the American Heart Association/American Stroke Association serves as the accrediting organization for the Summit.

Please allow time to complete the online form completely. If you exit the form to complete it at a later time, you will need to start over.

If you have any questions regarding the Speaker Confirmation Form, please contact Kayleigh Newell 518-312-1812 (cell).

Question Title

* 1. Please type your information with appropriate upper and lower case characters. Please do not use all caps or all lower case as this information will be used as it is entered for marketing materials.

You must complete all the fields in this question in order to move forward - if you would like to leave a field blank please indicate so by typing n/a in the field.

First Name

Last Name

Credentials

Title

Affiliation

Address 1

Address 2

City

State

Zip

Email Address

Cell Phone

Office Phone

Question Title

* 2. Please indicate how you would like your name to appear on all printed materials, for example:

John Smith, MD, FAHA
Chief, Division of Cardiovascular Disease
Centertown Medical Center
Centertown, NY

Name, Credentials
Title
Affiliation (Do not abbreviate)
City/Town, State Abbreviation

Question Title

* 3. EMERGENCY CONTACT: Please list a personal contact who we should reach in event of an on-site or medical emergency.

Contact Name

Contact Phone

Contact Relationship

Question Title

Question Title

* 2. Please indicate how you would like your name to appear on all printed materials, for example:John Smith, MD, FAHAChief, Division of Cardiovascular DiseaseCentertown Medical CenterCentertown, NYName, CredentialsTitleAffiliation (Do not abbreviate) City/Town, State Abbreviation

Question Title

* 3. EMERGENCY CONTACT: Please list a personal contact who we should reach in event of an on-site or medical emergency.

* 2. Please indicate how you would like your name to appear on all printed materials, for example:

John Smith, MD, FAHA
Chief, Division of Cardiovascular Disease
Centertown Medical Center
Centertown, NY

Name, Credentials
Title
Affiliation (Do not abbreviate)
City/Town, State Abbreviation