ABHP - Association of Black Health-System Pharmacists

SpeakersBureau

SPEAKERS BUREAU APPLICATION

In an effort to identify qualified speakers for educational programming, the ABHP Educational Affairs Council is developing a Speaker's Bureau. If you are interested in being listed on the Speaker's Bureau, please complete this online application and attach your CV. If your CV is unavailable at this time, send it later to abhp@myabhp.org. Members and non-members are encouraged to apply. You may be contacted for presentation opportunities upon review of your material.

Name *

Preferred Mailing Address *

City *

State *

E-mail Address: *

Daytime Phone Number *

Highest Degree Earned (check one) *
Bachelor of Science - BS Doctor of Pharmacy - PharmD Master of Science - MS Master of Business Adm - MBA Doctor of Philosophy - PhD
Other

ABHP Member? (check one) *
YES NO
Name of Employer *

What is your primary position? (check one)
Director of Pharmacy Associate or Assistant Director of Pharmacy Clinical Coordinator Supervisor or Manager Clinical Pharmacist Staff Pharmacist College and/or University Faculty Pharmacy Resident Pharmacy Student Pharmacy Technician Other, please specify
Other

Years of Practice (check one)
Less than 5 years 5 to 10 years More than 10 years
Primary Practice Setting (check all that apply) *
Community Pharmacy University Teaching Hospital Private (for profit) Hospital Government Hospital (county, city, fed) Government Agency (e.g. FDA, CDC, etc) Managed Care/HMO Mental Health Facility College of Pharmacy Pharmaceutical Industry Nursing Home, Skilled Care or Long Term Care Facility Home Care Organization
Other

What are your areas of expertise? (please check three)
Administrative Practice Ambulatory Care / Community Critical Care Medication Therapy Management General Clinical Practice Womens Health Infectious Diseases Clinical Service Management Psychopharmacy Oncology Cardiology Home Health Care Pediatrics Minority Health and Health Disparities Geriatrics / Long Term Care
Other

Prior Speakers Experience: (check all that apply) *
ABHP Minority Health Conference & Annual Meeting Regional Educational Conferences ABHP-ASHP Midyear Activities ASHP Midyear Meeting ASHP Annual Meeting Other Organization Meetings and Conferences (e.g, APhA, ACCP, etc) Local Association Meetings Provide lectures to students and residents Provide CE program lectures None
I am available to speak at the following ABHP programs: (check all that apply) *
ABHP Minority Health Conference & Annual Meeting ABHP-ASHP Midyear Educational Activities ABHP Regional Meetings ABHP Association Leadership Orientation Meeting
I approve for my information to be included in the Speakers Bureau online directory, with no exceptions *
YES NO
I approve for my information to be included in the Speakers Bureau online directory, with the exception of:
Address Phone Number Place of Employment Email Adddress
Do you wish for ABHP to mantained your information, but not include it in the online Speakers Burearu Directory
YES NO
Attach Your CV or Resume



* Required

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	Association of Black Health-System Pharmacists 2910 Kerry Forest Pkwy., D4-393 Tallahassee, FL 32309 Phone: (888) 834-0603 Fax: (850) 512-1821