MGB Consensus Conference - Faculty Identification Form Question Title * 1. Name & Title Etc. EXACTLY AS IT WILL APPEAR IN THE PROGRAM! Name: Title & Etc.: Institution: Address: City/Town: State/Province: ZIP/Postal Code: Country: Email Address: Phone Number: Question Title * 2. Would you be willing to act as Chairman of a Section of the Meeting? Thursday Morning Thursday Lunch Time Video Tips and Tricks Thursday Afternoon Thursday Dinner Meeting Friday Morning Friday Lunch Time Video Tips and Tricks Friday Afternoon Friday Dinner Meeting Saturday Morning Live Surgery Saturday Dinner Meeting Monday Lisbon Portugal Live Surgery Other (please specify) Question Title * 3. Would you be willing to act as MODERATOR of a Section of the Meeting? (You will move through the floor with the microphone, help take and direct questions to the Presenter and the Chairman. Keep a list of questions to be discussed and voted upon.) Thursday Morning Presentations Thursday Lunch Time Video Tips and Tricks Presentations Thursday Afternoon Presentations Friday Morning Presentations Friday Lunch Time Video Tips and Tricks Presentations Friday Afternoon Presentations Saturday Morning Live Surgery Presentations Monday Lisbon Portugal Live Surgery Presentations Other (please specify) Question Title * 4. Would you be willing to act as * RECORDER * of a Section of the Meeting? (You will KEEP A WRITTEN RECORD of questions to the Presenter and the Chairman and answers. You will keep a list of questions to be discussed and voted upon and record responses and votes.) Thursday Morning Presentations Thursday Lunch Time Video Tips and Tricks Presentations Thursday Afternoon Presentations Friday Morning Presentations Friday Lunch Time Video Tips and Tricks Presentations Friday Afternoon Presentations Saturday Morning Live Surgery Presentations Monday Lisbon Portugal Live Surgery Presentations Other (please specify) Title of Your FIRST Presentation (If you are Presenting) Title of Your Second Presentation (If you are Presenting) Title of Your Third Presentation (If you are Presenting) Question Title * 5. Other questions or suggestions... Done