Biographical Data Form

*Required fields

If you're registering for the first time, please complete the form below.

Returning visitor? Sign in here.

*First Name: *

*Last Name: *

If RN or MD, select degree type(s) :

*College/University Name: *

*School Location (city & state): *

*Email Address: If you need to change your email address please contact us. *

Confirm email address *

Please choose an eLearning ID consisting of 6-10 letters and/or numbers. We ask you to choose an ID so that we can keep your personal information private, and so that we can remember you when you return to the site.

Please write your eLearning ID down in a safe place and don't share it with anyone.

eLearning ID *

Confirm eLearning ID *

Home OR Business Address:

Country *

United States

Other

*Street Address: *

Street Address cont. (optional):

*City: *

*State: *

*Zip: *

*Day Telephone (123-123-1234): *

Are you a licensed RN/LVN/LPN? *

Yes

State where licensed *

RN/LVN/LPN license number *

*Position Title: *

*Hospital/Corporation: *

*Present Employer: *

*Faculty/Presenters: Describe your expertise in this topic. This should be a quantitative and qualitative set of statements. What qualifies you to present this topic? Training? How many years experience teaching the topic? Years of experience in the medical field? Do you have prior significant experience? If some is good, more is better. *

Teaching Experience:
Faculty qualifications call for one year of teaching experience in the previous two years. Sales people teach all the time, although they might not call it teaching. They might call it coaching, training, inservice, presentation, mentoring or sales call. It is teaching experience.

*With this in mind, and considering any previous employment experience, how much teaching (or how many teaching encounters) would you estimate you do annually? *

*How long have you been in sales? *

Please check your form over carefully before submitting it. Submitting the form will also sign you in.

Conflict of Interest Statement

Having an interest in an organization does not prevent a speaker from making a presentation, but the audience must be informed of this relationship prior to the start of the activity and any potential conflict must be resolved. In order to ensure balance, independence, objectivity and scientific rigor at all programs, the planners and faculty must make full disclosure indicating whether the planner, faculty or content specialist and/or his/her spouse family has any relationships with pharmaceutical companies, biomedical device manufacturers and/or corporations whose products or services are related to pertinent therapeutic areas.

Regarding conflict of interest: This field is pre-filled for you. If you are NOT an employee of a coproviding company, you will be contacted by phone once your form is submitted.

Is there a potential conflict of interest? *

Yes

If yes, list company(ies) with relationship:

Research Support

Speaker's Bureau

Consultant

Shareholder

Large Gift(s)

Other Support

Conflict of Interest Resolution

Presenter's electronic signature attests to his/her understanding and agreement to present information fairly and without bias.

Regarding the “signature”: This is an electronic or “typed” signature. Remember to date the signature and check the box.

*Signature: *

*Date (mm/dd/yyyy): *

* By checking this box, I am providing my electronic signature approving all the information entered. *

Thank you for participating in this program.