ANZSNM Speaker Competition Form

ANZSNM Conference

Applicant Information:

Name (last name, first name, middle initial) *

CAMRT Registration No.

Street Address

City

Province

Postal Code

Home Telephone

Email *

Professional Information:

Job Title

Department

Employment Institute

Address

City

Province

Postal Code

Work Telephone

Work Email

Application Requirements

Title of Presentation

Abstract *

An abstract of no more than 200 words that describes the proposed presentation. It should address a topic in nuclear medicine technology that is advanced, innovative or forward-thinking.

Objectives for the presentation *

Outline for the Presentation *

A CV (up to 3 pages) that includes information about the applicant’s speaking experience.

Please wait for confirmation page before clicking “Back” button or closing your browser as this will cancel your upload. If “upload fails” after several attempts please email the files to Phyllis Williams

Certification of Application *

In submitting a proposal, I confirm that I will be available to make this presentation, if selected, on the dates indicated for the conference.

Agree

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