BCPAS 2025 CME Conference Speaker Application

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Thank you for your interest in speaking at the Bexar County PA Society's 2025 CME Conference. The Conference will be held on Thursday, November 6 - Saturday November 8 at UT Health San Antonio (formerly UTHSCSA).

In exchange for your presentation, you will receive a $250 honorarium per presentation OR complementary conference registration. Maximum 2 presentations per speaker.

Name *

Credentials (ex. MD, PA-C, MS, FNP)
*

Email *

Affiliation
*

Address (to mail honorarium)
*

Cell phone number *

Presentation Title *

List 3 - 4 Learning Objectives
*

Short Speaker Bio (3-5 sentences)
*

Compensation Preference *

$250 Honorarium

Complementary Conference Registration Fee

Neither / Waive compensation

Disclosures & Financial Relationships

AAPA Faculty Disclosure Form
A conflict of interest may be considered to exist if a faculty member of an educational activity, or spouse or partner of that person, has financial relationships with the grantor or any commercial interest(s) that may have a direct impact on the content of the program. Financial relationship is defined as being a shareholder, consultant, grant recipient, research participant, employee, and/or recipient of other financial or material support. The participants in this CME activity must be made aware of any such financial relationship(s). Full disclosure of any such financial relationship is required of all persons who may have control over the content.
This disclosure policy is intended to protect all parties involved from any potential conflict of interest that may arise. AAPA assumes responsibility for resolving these conflicts of interest.

Do you have any disclosures?
*

Column 1

Yes (please describe in comments section)

Do you have a financial relationship or commercial interest with any of these? (please list relationship or interest in comments section)
*

Honorarium

Consultant

Grants / Research Shareholder

Other financial / material support

Speaker's Bureau

Employee

Other disclosure

No financial relationships or commercial interests

Required

Comments

Signature & Date

I attest that this form has truthfully completed to the best of my knowledge. I agree to submit my presentation to BCPAS at least 2 weeks prior to the conference date.

Name *

Date *

YYYY

Submit

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