Chair/Co-Chair/Vice Chair Information Form

"*" indicates required fields

General Information

Name*

First Last

Credentials*

Please use all uppercase letters (MD, PhD). Please refrain from using periods (M.D., P.h.D.) Be sure to enter your credentials exactly as they should appear in meeting related materials or messaging.

Institution*

Please provide us with the institution that you are currently at, not where you received your education. Please refrain from using acronyms (UCLA, GSU, FSU). Be sure to enter your institution name exactly as it should appear in any meeting related materials or messaging.

Primary Title*

Primary Department*

Primary Affiliation*

Email*

Assistant's Name

First Last

Assistant's Phone Number

Assistant's Email

Session Type*

Session Title*

Biography Narrative

If you would like to use a previously submitted biography, please select that option below. Otherwise, you will have the option to upload a new biography.

Please select one option:*

I would like to use my previously submitted biography.

I would like to upload a new biography.

Biography Narrative*

100 words or less

Professional Headshot

If you would like to use a previously submitted professional headshot, please select that option below. Otherwise, you will have the option to upload a new professional headshot.

Please select one option:*

I would like to use my previously submitted professional headshot.

I would like to upload a new professional headshot.

Professional Headshot*

Accepted file types: jpg, jpeg, png, Max. file size: 10 MB.