ISMRT Emerging Regions Initiative Application

ISMRT Emerging Regions Initiative
Application

Request for Virtual Meeting Assistance

"*" indicates required fields

Your ISMRT Membership ID Number*

Your Name

First Last

Your Email*

Name of Emerging Region*

Preferred Month for Hosting Virtual Meeting*

September

October

Both September and October are acceptable

Speaker & Presentation Details
For two or three 30-minute presentations.

Speaker #1

1) Name*

First Last

2) Professional Title*

3) Current Place of Employment*

4a) Email*

4b) Phone*

5) Biography*

25-50 words or less.

6) Title of Presentation*

7) Brief Overview/Summary of Presentation*

8) Target Audience for Presentation*

9) Objectives of Presentation*

What are 2 or 3 things the audience will learn?
One objective per row.
Click the (+) icon to add more rows.

10) Professional Photograph/Headshot*

Photo will be used for promotion of event.

Accepted file types: jpg, png, pdf, Max. file size: 24 MB.

Speaker #2

11) Name*

First Last

12) Professional Title*

13) Current Place of Employment*

14a) Email*

14b) Phone*

15) Biography*

25-50 words or less.

16) Title of Presentation*

17) Brief Overview/Summary of Presentation*

18) Target Audience for Presentation*

19) Objectives of Presentation*

What are 2 or 3 things the audience will learn?
One objective per row.
Click the (+) icon to add more rows.

20) Professional Photograph/Headshot*

Photo will be used for promotion of event.

Accepted file types: jpg, png, pdf, Max. file size: 24 MB.

Speaker #3

Leave these fields blank if you do not have a third speaker.

21) Name

First Last

22) Professional Title

23) Current Place of Employment

24a) Email

24b) Phone

25) Biography

25-50 words or less.

26) Title of Presentation

27) Brief Overview/Summary of Presentation

28) Target Audience for Presentation

29) Objectives of Presentation

What are 2 or 3 things the audience will learn?
One objective per row.
Click the (+) icon to add more rows.

30) Professional Photograph/Headshot

Photo will be used for promotion of event.

Accepted file types: jpg, png, pdf, Max. file size: 24 MB.