AKMG 2018 CME

_Speaker Commitment Form

Name *

Degrees *

E-Mail *

Job Title *

Cell Phone *

Brief Biography (350 words max) *

Bio and Headshot agreement

Title of Talk *

Learning Objectives *

Please download the mandatory University of Ottawa Conflict of Interest (COI) form below.
The COI form has to be complete with signature and mailed to akmgcme2018@gmail.com by February 10, 2018.
Please email / file portal your presentations to akmgcme2018@gmail.com by July 27, 2018.
The use of the AKMG CME Slide Kit/Template with disclosure pages is mandatory.
The slide template can be downloaded below.
Your presentations will be uploaded and ready for your session.
Due to AV arrangements and restrictions, personal laptops will not be permitted.
Please keep within your allotted time.

Disclosures *

Please list all conflicts of interests in the last 2 years (If applicable)

I agree to participate in the ‘Updates and Innovations in Patient Care and Medical Practice’ CME *

I agree to the terms as listed on this form *

I will use generic rather than trade names of medications and/or devices included within all presentations or written materials *

I will use the mandatory slide template for disclosing COI *

I have downloaded the University of Ottawa COI form and will send it completed to akmgcme2018@gmail.com *

(Deadline for submission of completed form to akmgcme2018@gmail.com with signatures is February 10, 2018)

Signature (Enter Name Below) *

2 + 2 = ? Please prove that you are human by solving the equation *