Speaker Registration ACPNJ Speakers Bureau If you are human, leave this field blank. Speaker Information Salutation * Dr. Mr. Mrs. Ms. Prof. First name * Last Name * Credentials Job Title System/Affiliation * Specialty (Please check all that apply) Internal Medicine Cardiology Geriatrics Hematology Hospital Infectious Disease Oncology Palliative Care / Hospice Public Health / Epidemiology Pulmonary Medicine Rheumatology Surgery Other Specialty (Please check all that apply) Email Address * Phone Number * Phone Number 2 Office Contact Person Address Address Address Address City City State/Province* Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province* Zip/Postal Zip/Postal LinkedIn Profile Twitter Profile Facebook Profile Upload Curriculum Vitae Drop a file here or click to upload Choose File Maximum upload size: 33.549999999999997MB Upload Headshot Drop a file here or click to upload Choose File Maximum upload size: 33.549999999999997MB Speaker Bio (Please add a brief bio) Speaking Topics Speaking Topics by Subspecialty * Adolescent Medicine Allergy and Immunology Business and Practice Management Cardiology Endocrinology and Metabolic Diseases Gastroenterology Geriatrics and Palliative Care Hematology and Oncology Infectious Disease Nephrology Neurology Primary Care Public Health Pulmonology Rheumatology Sports Medicine Women's Health Other Speaking Topics by Subspecialty Specific Topics Upload Sample Presentation Drop a file here or click to upload Choose File Maximum upload size: 33.549999999999997MB Link to Sample Presentation (If a sample presentation is online, please provide the web address) Honorarium (Staff only) Add Remove Logistics How far will you travel to speak? * Anywhere Up to 50 miles 2 Hours or Less New Jersey only NJ/NYC/Eastern PA Will not travel OtherOther
