Your Personal InformationSpeaker Name* First Last Your Email* Mobile Number* Upload Speaker BioAccepted file types: pdf, docx, doc, pages, Max. file size: 25 MB.Upload Speaker HeadshotAccepted file types: jpg, gif, png, jpeg, Max. file size: 10 MB.Are there co-speakers for your session? Yes No Your SessionProgram Name* Program Date MM slash DD slash YYYY Session Title* Session Description*Objectives of your SessionLearning ObjectivesList 2-3 Learning Objectives for your Session (Behavior-Based and/or Measurable) After this course, attendees will be able to:Learning Objective #1 Learning Objective #2 Learning Objective #3 Disclosure of InterestsMedAudPro requires that all speakers, faculty and planning committee members complete a Disclosure Statement so that relevant relationships with commercial interests are identified and any potential conflicts of interest are resolved prior to the CME program. Please note that MedAudPro defines “relevant” as any relationship/dollar amount in the past 12 months. A commercial interest is any entity that produces, markets, re-sells, or distributes health care goods or services consumed by, or used on, patients.Consent to Commercial Interests I DO NOT have a relevant relationship with any commercial interest(s), and neither does my spouse/partner. I DO have a relevant relationship with a commercial interest(s). Please specify relationships below; indicate if the relationship is for you, your spouse or partner. Disclosure of commercial interestCompany NameRelationshipSelf, Spouse, or Partner Off Label/Investigational Product Disclosure I WILL NOT be discussing off label/investigational use of a commercial product or device. I WILL be discussing off label/investigational use of a commercial product or device. MedAudPro does not imply that such relationships will prevent the speaker/committee member from making an unbiased presentation/decision. However, it is imperative that such relationships be identified so that MedAudPro can determine work to resolve any conflict(s) of interest, should one arise.