Adjunct Symposium Proposal Form

To be considered by the AAPA Conference Education Program Committee for inclusion in the Adjunct Symposia Program at the 36th Annual PA Conference, you must complete and submit this form no later than Monday, January 14, 2008. Prior to submitting this form, you must first read and agree to the AAPA Guidelines for Adjunct Symposia. Notification of the status of proposals will be sent by February 4, 2008. No incomplete proposals will be considered.

DEADLINE EXTENDED TO FRIDAY, JANUARY 18!

Title of Program (exactly as it should appear on all conference materials)

List three to five learning objectives: At the conclusion of the program, participants will be able to...

Options (Select One)

Breakfast ($26,000 fee, 6:30 - 7:45 a.m.)

Breakfast including Web cast ($38,500 fee, 6:30 - 7:45 a.m.)

Dinner ($31,000 fee, 5:30 - 8:00 p.m.)

Dinner including Web cast ($43,500 fee, 5:30 - 8:00 p.m.)

Additional comments

I do not know if I want the optional Web cast; please send more information.

I will accept a breakfast or a dinner time slot if necessary.

Other

Preferred Day - First Choice

Preferred Day - Second Choice

Preferred Day - Third Choice

Program Chair (current curriculum vitae must be sent)

PA Moderator/Speaker - Required (current curriculum vitae must be sent)

Additional Faculty (current curriculum vitae must be sent)

Proposal submitted by

Provider Name

Company

E-mail

Phone

Fax

Address

City/State/Zip

Commercial Support (A copy of the letter of support for this program must also be sent)

Contact Name

Full Company Name (be precise)

E-mail

Phone

Fax

Address

City/State/Zip

I have read and accept the AAPA Guidelines for Adjunct Symposia.