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2021 Call For Speakers/Writers Before you begin...
Speakers: Review the AzPA Speaker's Handbook , if you have not already done so and/or are new to our organization, prior to filling out this application.
Writers: If you are interested in submitting a written manuscript or CE article for the Arizona Journal of Pharmacy please fill out applicable information and refer to the AJP Guidelines prior to filling out this applicaiton.
Speaker/Author Information
First Name *
Last Name *
Email *
Cell phone *
Address *
City *
State/Province *
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
American Samoa
Federated States of Micronesia
Guam
Marshall Islands
Northern Mariana Islands
Palau
Puerto Rico
U.S. Minor Outlying Islands
Virgin Islands
Armed Forces Americas
Armed Forces Europe, the Middle East, an
Armed Forces Pacific
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Northwest Territories
Nunavut Territory
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon Territory
Zip *
Company Name *
Title *
Professional License/Degree
PharmD RPh CPhT BS MS PhD MBA MD MPH RN NP
Board Certifications
AAHIVS BCACP BCCCP BCCP BCIDP BCNP BCNSP BCOP BCPA BCPD BCPP BCPPS BCPS CCGP CDE CGP CPNP CSPI DABAT
Please list any co-presenters or co-authors here: Include name, credentials and title
Please provide a bio of 240 words or less: *
Presentation/Article Information
Title: Formulate a title that clearly states the topic to be presented. Keep in mind that "catchy titles" may help build interest in your presentation *
What are the intended educational goals and focus of your presentation/article? *
LEARNING OBJECTIVES: The intent of learning objectives is to provide learners with clear direction regarding the information, skills and/or abilities they should be able to achieve at the end of the program. Learning objectives need to be specific and measurable. Examples include: compare/contrast, define, demonstrate, describe, differentiate, identify, list, and recognize. Avoid using "know" and understand" as these terms do not specificall state at what level the information is understood.
Please list the pharmacist learning objectives below: *
Please list technician objectives below (if applicable)-must be within their scope of practice:
Commercial Interest Disclosure
List the names of proprietary entities producing health care goods or services, with the exemption of non-profit or government organizations and non-health care related companies with which you or your spouse/partner have, or have had, a relevant financial relationship within the past 12 months.
Please list the entity below and if it pertains to you or your spouse/partner: *
Describe the role you and/or your spouse/partner has with the entity role and any if any benefits or compensation are given in exchange for that role: *
Consents:
Optional: (will be required if your program/article is approved)
If you have any extra information you would like to include such as a CV, picture, assessment questions, slides, article, etc. you would like to submit please send it directly to us at education@azpharmacy.org and reference 2021 Call for Speakers -Supplemental Info in the subject line.