Proposal Live Webinar form

Proposal for APTA NC Live Webinar Presentation

Name:

Email:

Phone:

APTA #

Prof. Designation

Employer/Occupation

Presentation Title

Description (100-200 words)

Presentation level

Basic

Interm.

Advanced

3-5 Objectives (At the end of this presentation, the attendee will _________)

References (5 within 10 years, AMA style)

Speaker Biography (50-150 words)

Choose Live, On-Demand, or Both

Live

Recorded

Both

Consent to Record

Yes

Length of Presentation

If longer than 1.5 hrs, write hr-by-hr agenda

Presentation Disclosure

1. Individual with relationship

2. Describe financial interest and/or entity creating actual or potential conflict

3. Describ relationship between financial interest and/or entity and webinar content

Upload CV or resume

Upload Headshot photo

Topic Specific Logo or Picture

IF ON-DEMAND, requires 10 post-presentation multiple choice and true/false test questions, here (pls note correct answes)