Test Form

INSTRUCTIONS: The faculty form has been updated and simplified. Simply answer a few questions and upload an abbreviated CV. You cannot save the information – once you begin, it must be completed at one time.

* Denotes Required Fields

Contact Information

Name*:

Email*:

Board Certification in*:  Plastic Surgery Facial Plastic Surgery Otolaryngology/ENT

Indicate if you are a Resident/Fellow/Medical Student*:  Resident Fellow Medical Student

Please choose your areas of participation:

 Speaker/Panelist Moderator Discussant

Faculty Acceptance of Responsibility:

  • I certify that the appropriate medical/patient releases for photography and the subsequent use in presentations has been obtained.
  • I certify that all copies of printed material has the permission of the author, and that my use of such material will not violate any copyright laws.
  • I understand that failure to comply may necessitate termination of my presentation.

AV Equipment for PowerPoint Presentations:

We will have all necessary equipment available for your PowerPoint presentation. All presentations are
to be uploaded in advance. You will be emailed with instructions for uploading along with the due date.
Please Note: If you choose to use another format on your own computer, please bring any necessary
cables needed for a quick and easy connection to the equipment available in the program room.

Which Organization do you belong to?*  ASPS ASAPS Other
If other, please list equivalent organization here:*

ASPS - ID#: 

ASAPS - ID#:

Upload CV here (doc, docx, pdf):*

By typing your name in the box below, you are indicating your acceptance of all the above.

Electronic Signature*:

Click send button below to direct your form and CV directly to the Executive Office