NYSAND Speaker Application

Name(required)

Professional Designation(s)

Job Title

Company

Address

Phone Number

Email Address

Will you have a co-presenter?(required)

Yes No

If yes, please have co-presenter fill out a separate presenter application form and indicate below who the co-presenter will be.

Co-Presenter Name(s)

HONORARIUM & EXPENSE INFORMATION

If necessary, please state requested honorarium

Expected additional expenses, if any

SESSION INFORMATION

Summary of Session – In 75 words or less, please provide a summary of the content. If you are selected to present, the description submitted below will be used in promotional brochures and on the conference website. Please Note: We reserve the right to change and/or reduce your title/description for program clarity.(required)

Learning Objective – Provide a one-sentence primary learning objective of your presentation. Please do not give bullet points, multiple objectives joined by semi-colons, or several sentences. Example: This session will help you prepare for changes in the profession by examining and discussing emerging issues in nutrition and their effect on day-to-day Dietitian responsibilities.(required)

Learning Need Codes – Please suggest 3 codes from the CPE Learning Need Codes list linked belowPlease find the CDR Learning Needs Code List Here(required)

Performance Indicators – Please suggest 4 Performance Indicators from the CPE PI list linked belowPlease find the new CDR Competencies Performance Indicators Listed Here(required)

Biographical Sketch – In 75-100 words, provide a sketch of your background and professional experience showing your qualifications to present on the subject area. If you are selected to present, the description submitted below will be used in promotional brochures and on the conference website.(required)