65th Annual SGS Fall Assembly – Faculty Information

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2023 SGS Fall Assembly - Faculty Confirmation & Information Form

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• Presenter Information

  (As you would like it to appear in marketing materials.)
• Name*
  First Last Credentials
• Position Title
• Institution/Hospital/Company:
• Mailing Address
  Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country
• Cell Phone
• Fax
• Email*
• Honorarium
  • I would like to donate my honorarium back to the Seattle Gynecologic Society
• Number of Presentations*
  One PresentaionTwo Presentations

• Presentation Details

  The following section MUST be completed for CME documentation purposes. If you are delivering more than one presentation, please use a different page for each of your topics. Should this section not be adequately addressed, CME for this activity may not be awarded.
• Presentation / Topic Name(s):*
  (as you would like it to appear in the catalog):

• ACOG Activity Gap Analysis:

  The following section MUST be completed for CME documentation purposes. If you are delivering more than one presentation, please use a different page for each of your topics. Should this section not be adequately addressed, CME for this activity may not be awarded.

• Professional practice gap:*
  Please describe the professional practice gap that underlies the need that your talk will address for the intended target audience. (The difference between current practice and best practice is the professional practice gap.)
• You must cite your sources. Where did you get your information?*
• To adhere to ACOG policy you must also attach PDF copies of the articles referenced.*
  Drop files here or Select files

  Accepted file types: pdf, Max. file size: 256 MB.
• Educational Need:*
• Learning Objective:
  At the end of this conference, learners should be able to?:
• Desired Result:*

• Second Presentation Details

  The following section MUST be completed for CME documentation purposes. If you are delivering more than one presentation, please use a different page for each of your topics. Should this section not be adequately addressed, CME for this activity may not be awarded.
• Second Pesentation / Topic Name(s):*
  (as you would like it to appear in the catalog):

• ACOG Activity Gap Analysis:

  The following section MUST be completed for CME documentation purposes. If you are delivering more than one presentation, please use a different page for each of your topics. Should this section not be adequately addressed, CME for this activity may not be awarded.

• Professional practice gap - Presentation 2:*
  Please describe the professional practice gap that underlies the need that your talk will address for the intended target audience. (The difference between current practice and best practice is the professional practice gap.)
• You must cite your sources. Where did you get your information?*
• To adhere to ACOG policy you must also attach PDF copies of the articles referenced.*
  Drop files here or Select files

  Accepted file types: pdf, Max. file size: 256 MB.
• Educational Need:*
• Learning Objective:
  At the end of this conference, learners should be able to?:
• Desired Result:*

• Audio/Visual

• Audio/Visual Requests*
  • I will not be making a visual presentation
  • I need a projector and screen
  • I prefer a podium
  • I need a handheld microphone
  • Other A/V requests:
• Other A/V Requests

• Attention Mac Laptop Users

  If you plan to use your own Mac Laptop for your presentation, you must bring your own computer to VGA or HDMI Adapter Cable.

  This cable varies greatly from one Mac Laptop to another. The cable is necessary to connect your laptop to the projector.

• CAPTCHA

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