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55th Annual CME Meeting
June 4 - 6, 2010
Ritz-Carlton, Amelia Island, Florida
SPEAKER FORMS
Contact Info, Bio, Itinerary | Educational Objectives | Presentation Requirements | Disclosure
Contact Info, Bio, Itinerary
These forms are for faculty that have been invited to speak at the GSD Meeting and
are currently on the program agenda as chosen by the GSD Program Director.
Speaker Name *
Email Address *
Required entries with every submission*
CONTACT INFORMATION
Please list how you wish to be listed in the program
Mailing address
Office Phone
Mobile Phone
Home Phone
Fax
Assistant's Name
Assistant's Phone
Assistant's Email Address
BIO (used in the Meeting Program and excerpts taken for verbal introduction)
CME
I am seeking CME credit for this meeting
I am NOT seeking CME credit for this meeting.
TRAVEL
I am driving to and from the meeting location (skip ahead to ACCOMMODATIONS)
I am FLYING to and from the meeting location (please complete Arrival/Departure info below)
ARRIVAL
I DO / I DO NOT wish to be shuttled from the airport to the hotel and will arrange own grand transportation
Airport Airline
Arrival date Flight Number Arrival Time
DEPARTURE
I DO / I DO NOT wish to be shuttled from the hotel to the airport and will arrange own grand transportation
Departure date Flight Number Departure Time
ACCOMMODATIONS
I have been told the GSD will make my room reservation at the resort.
OR
I understand I will be making my own room reservation at the resort. Make your accommodations reservation at the Ritz Carlton, Amelia Island by calling 800-241-3333 and book under the Georgia Society of Dermatologists room block. The room block EXPIRES May 3.
Please complete the following in either case,
I will be checking in on
I will be checking out on
GUESTS - Guest expenses are the responsibility of the speaker. Please list the names of your guests (spouse, children/ages, relatives, guests, etc.)
Name , Relationship , Age (if under 18)
ACTIVITIES - sign me and/or my guests up for the following:
FRIDAY
Cocktail Reception - Friday, 5:30 - 7:00 p.m., number attending
Children's Activity (ages 3 - 8), 5:30 - 7:00 p.m., number attending
Tween Movie Room (ages 8 - 14), 5:30 - 7:00 p.m., number attending
SATURDAY
Family Luau & Dinner - Saturday, 6:30 p.m., total number attending , ages of any children attending
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last updated May 06, 2010