2015 ACVIM Forum Scientific Session Submission Form
Presentation Title
*
Presenter's Name
*
Presenter's Bio (this will be used in print)
*
Designation (DVM, PhD, etc)
ACVIM Diplomate
Yes
No
Practice/Organzation Name
Job Title/Position
Street Address
Street Address Line Two
City
State/Province
Country
Zip/Postal Code
Phone Number
*
Email Address
*
Is this Lecture Part of a Series?
Yes
No
Does this proposed topic have more than one speaker?
Yes
No
If "Yes" please add the name of the additional speaker
Lecture Type/Session Description
Comprehensive Review Lectures
Post-Graduate Courses
Clinical Workshops
Technician Program
Lecture Audience
Small Animal
Equine
Food Animal
Cardiology
Oncology
Neurology
Preferred Lecture Category
Cardiology
Neurology
Oncology
Endocrinology
Gastroenterology
Hematology
Hepatology
Immunology
Inf. Disease
Nephrology/Urology Nutrition/Metabolism
Pharmacology
Respiratory
Bus. Management
Other
If "Other" please explain
Secondary Lecture Category
Small Animal
Equine
Food Animal
Cardiology
Oncology
Neurology
If "Other" please explain
50 Word Session Description (to be used in marketing materials)
*
Do you know of any companies that may be potential sponsors for this topic? **If yes, please provide the company's name and a contact person.
Special Requests/Comments
Submitter info and email
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Full Name
*
Prefix
First Name
Last Name
Email
*
Phone Number
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Area Code
Phone Number
Thank you for submitting your lecture details to the ACVIM Forum Program Committee. All communication regarding this submission will be sent to the submitter email listed above. You will receive an email confirmation of receipt of this submission.
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