Faculy Profile Form

This form is used to gather information on potential speakers for future MCEP conference. Please complete this faculty profile form, then send your current CV, to MCEP’s CME Coordinator, Christy Snitgen, by fax (517) 327-7530 or by e-mail to mcep@mcep.org.

MCEP will keep your information on file for future conferences such as the Summer Assembly or the Winter Symposium. The topics for our conferences are chosen by our Education Committee. If a speaker for a given topic is needed for a conference, faculty profile forms will be used as part of the process to identify potential speakers. Invited speakers will be contacted using the information you provide on this form. If your name is not chosen, your faculty profile will remain on file for consideration during the planning of future conferences.

Thank you for taking the time to let MCEP know of your interest in speaking.

* 1. Please fill out your contact information

* 2. Designation:

* 3. Contact Information:

* 4. Areas in which you are willing or interested in speaking:

* 5. If MCEP learns of speaking opportunities outside of MCEP courses, may we share your information with outside organizations such as residency programs, professional organizations, etc.?