AzPA Podcast Speaker Request Form

First Name *

Last Name *

Email *

Phone *

Please select one: *

I will be the speaker
I am recommending someone else (They have agreed)

Select purpose: *

Pharmacy News
General Announcement
Clinical Update
Interview
Other

If other please indicate purpose below

Would your topic be appropriate to offer CE for? *

Yes
No
Not Sure

If you answered yes to CE above please list 1-2 learning objectives below:

If you are recommending someone else please list their name and contact information below.

What field of pharmacy do you currently practice in? *

What topic are you interested in speaking about? *

Describe your qualifications in speaking on this topic. *

When would you like to record your podcast? *

Thank you for your interest. We will be in contact with you shortly!

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