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

Question Title

* Full Name

Question Title

* Primary Phone Number

Question Title

* Secondary Phone Number

Question Title

* Preferred Email Address

Question Title

* Primary Institution Name

Question Title

* City / State / Country

Question Title

* Are you a Fellow (FACMT) of ACMT?

Question Title

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

Question Title

* Are you a member of the ACMT International Committee?

Question Title

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

Question Title

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

Question Title

* 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.)?

Question Title

* 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.)

Question Title

* 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.

Question Title

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

( Privacy & Cookie Notice

T