CPE Faculty Questionnaire - Louisiana Pharmacists Association

CPE Faculty Questionnaire

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Please complete the following information.

BIOGRAPHICAL INFORMATION
Full Name *		Degree
Business Name *		Position/Title *
Street Address		City, State, Zip *
Phone Number		Fax Number
Email Address *
Please indicate if you would like us to use a previous CV or Resume on File or if you will be providing a new one. You may upload here or email to info@louisianapharmacists.com
CV / Resume *
Upload CV/ResumePDF or Word preferred.
Biography ParagraphPlease provide a brief paragraph format biography to be included in program.
HeadshotPlease upload a headshot to be used in the final program.
ON-SITE CONTACT INFORMATION
Please provide a the following information about the time you are on-site at the convention.
Cell Phone Number *
Emergency Contact Name and Phone Number
Planned Arrival and Departure Dates at the Convention:As a faculty member, you are invited to attend all planned functions during the convention (exception: participation in the Golf Tournament requires pre-registration and $100 green fee). For our planning purposes, please indicate your anticipated days of arrival and departure.
WORKING TITLE OF ACTIVITY
Please provide a tentative title for your activity to be featured on marketing materials. This title must only be finalized with the submission of the CPE Activity Grid.
Title *
ACCOMMODATIONS
See Honorarium Policy for expenses and services provided by LPA. Staff will be in contact upon receipt of this document to make arrangements as needed.
Requested Room Night(s) as per Honorarium
Preferred Bed TypeLPA will request your preferred room type. However, this cannot be guaranteed.
PAYMENT INFORMATION
For any payment transactions, as per your Honorarium Agreement, please provide the following information. (All information is secure and remains confidential.)
Check Payable to:Your name or the name of the organization
Mail Check to:
Social Security # / Tax ID #:
ADDITIONAL COMMENTS AND QUESTIONS
Please let us know any other comments or questions you may have at this time.
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