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Speakers Bureau Application

	In an effort to identify qualified speakers for educational programming, the ABHP Educational Affairs Council is developing a Speakers Bureau. If you are interested in being listed in the Speakers Bureau's directory, please complete the online application and submit your CV. If you CV is unavailable at this time, send it to [email protected].
ABHP Member (*)	YESNO Invalid Input
Name (*)	Invalid Input
Preferred Mailing Address (*)	Invalid Input
City (*)	Invalid Input
State and Zip Code (*)	Invalid Input
Name of Employer (*)	Invalid Input
Email Address (*)	Invalid Input
Day Time Phone Number (*)	Invalid Input

Highest Degree Earned (*)	Bachelor of Science BS Doctor of Pharmacy PharmD Master of Science MS Master of Business Adm MBA Doctor of Philosophy Invalid Input
Other degrees earned	Invalid Input
List any Certificates or Certifications	Invalid Input

What is your primary position (*)	Director of Pharmacy Assistant Director of Pharmacy Clinical Coordinator Supervisor or Manager Clinical Pharmacist Staff Pharmacist College or University Faculty Invalid Input
List other titles not included above	Invalid Input

Years in Practice (*)	Invalid Input
Primary Practice Setting (*)	Community Pharmacy Hospital Government Agency Managed Care HMO Mental Health Facility College of Pharmacy Pharmaceutical Industry Invalid Input
List other practice setting not included above	Invalid Input

What are your areas of expertise (*)	Administrative Practice Ambulatory Care Critical Care Management Medication Therapy Management General Clinical Practice Womens Health Infectious Diseases Clinical Service Management Psychopharmacy Oncology Cardiology Pediatrics Invalid Input
List other areas of expertise not included above	Invalid Input

Prior speakers experience (*)	National Conferences and Meetings State Conferences and Meetings Local Conferences and Meetings International Conferences and Meetings ABHP Educational Conferences Provide lecturs to students and residents None Invalid Input

I approve for my information to be included in the Speakers Bureau online directory with the exception of (*)	Address Phone Number Place of Employment Email address Maintain but do not include in the online directory Invalid Input
Attach your CV (*)	Invalid Input
Verification Code	Invalid Input

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Association of Black Health-System Pharmacists
2129 FM 2920, Suite 190 #137
Spring, TX 77388
Phone: (800) 756-7215
Fax: (713) 481-1870

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