Thank you for your interest in participating in the ACMT International Committee Speakers' List. Please complete the application form below as completely as possible.

* Full Name

* Primary Phone Number

* Secondary Phone Number

* Preferred Email Address

* Primary Institution Name

* City / State / Country

* Are you a Fellow (FACMT) of ACMT?

* Are you a current or past member of the ACMT?

* Are you a member of the ACMT International Committee?

* List languages, other than English, in which you are sufficiently fluent to teach toxicology to a professional audience?

* Please include any relevant hospital, community, professional or ACMT-related titles below.

* In the past 2 years, how often have you been asked to speak in a public forum (outside of any course or departmental lectures, etc.)?

* Please indicate topics you would like to speak about for the options below. If you would like to speak on any topics not included here, please select "Other" and specify your topic in the next question. (Topics related to the practice of toxicology in middle- and low-income countries are especially welcome.)

* Please include any relevant information about your role or expertise that qualifies you to speak on these topics, or email a copy of your CV to info@acmt.net and include 'International Speaker Application' in the subject line.

Please read carefully and acknowledge below.

Yes, I am interested in becoming part of ACMT's International Speakers List. I understand that my name, state, e-mail address, resume, bio and area(s) of expertise will be made publicly available by ACMT for the exclusive purposes of promoting the International Committee Spokespersons List, and that interested organizations may contact me directly to request a speaking engagement. I understand that I may not solicit any fees or honorarium (An exception of reasonable travel expenses may be made whereas agreed to by me and any interested parties). In addition, I agree [to the best of my ability] to convey ACMT's messages in order to promote its goals and objectives.

* By typing your name below, you electronically acknowledge that you have read and agree to the terms above.

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