Speaker Needs Form - Michigan Dental Association

Speaker Information

NAME(Required)

First Last

CREDENTIALS

YOUR TITLE(Required)

MAILING ADDRESS

Street Address Address Line 2 City State ZIP Code

WORK PHONE

CELL PHONE(Required)

EMAIL(Required)

ADA NUMBER (Dentists Only)

UPLOAD YOUR W-9

Drop files here or

Accepted file types: pdf, jpg, png, Max. file size: 2 MB.

Equipment Requirements

What type of laptop will you be using?

Please list all audio/visual requirements you will need for your presentation, including microphone type.

(NOTE: Speakers are required to bring their own laptop.)

Housing Requirements

The Michigan Dental Association normally pays for your room the night before your presentation unless contract specifies otherwise. The MDA is not responsible for additional nights or additional in-room person charges or expenses.

NUMBER OF NIGHTS REQUIRED

NAME(S) OF ACCOMPANY GUESTS

Separate names with commas.

SPECIAL REQUESTS

Biographical Information

Enter your preferred wording (150 words or less) describing your background, accomplishments, and qualifications.

Course Information

Please input your suggested wording in 150 words or less, a synopsis/summary of your program (including bulleted learning objectives) that can be used for publication purposes. NOTE: The MDA will shorten the synopsis to fit space requirements. Include the following information:

Bulleted learning objectives (minimum of three).
Unique aspects of the program.
Any benefits the audience will derive from attending this program.
Who will benefit from this program (i.e. dentists, hygienists, assistants, business staff).
The immediate “pay-offs” to attending the program.

FIRST COURSE TITLE

NOTE: Titles must be kept under 100 characters (including spaces).

FIRST COURSE DESCRIPTION

NOTE: Course descriptions must be 1,000 characters (including spaces) or less.

AUDIENCE (First Course)

DDS

Assistants

Hygienists

Entire Dental Team

SECOND COURSE TITLE

NOTE: Titles must be kept under 100 characters (including spaces).

SECOND COURSE DESCRIPTION

NOTE: Course descriptions must be 1,000 characters (including spaces) or less.

AUDIENCE (Second Course)

DDS

Assistants

Hygienists

Entire Dental Team

Course Handouts

Please view the MDA's Speaker Handout Rules.

Will your handout originals be sent to the MDA 30 days in advance of program for copying (CE seminar) or posting online (Annual Session)?

Yes

NOTE: MDA does not reimburse for copying. Materials must be received 30 days prior to program date either by mail or email.

File Upload: Use the feature below to include your presentation handouts with this form submission. Submit all handouts in PDF format. For Powerpoint presentations, choose the 3 Slides choice in your Print Options menu before converting to PDF. NOTE: Name your handouts to match your course title.

UPLOAD HANDOUT(S) (First Course)

Drop files here or

Accepted file types: pdf, Max. file size: 10 MB.

UPLOAD HANDOUT(S) (Second Course)

Drop files here or

Accepted file types: pdf, Max. file size: 10 MB.

Photograph

The MDA requires a high-resolution, color, professional portrait (see examples below). Please follow these guidelines:

Send the original digital image.
Do not send an image copied from your website.
Only send .jpg or .png images.

Photos meeting these requirements can be attached to this form using the upload option below. If you must send a printed image by mail, please write your name on the back. NOTE: Photos will not accompany course descriptions of speakers who do not send images meeting these requirements.

UPLOAD PHOTO

Accepted file types: jpg, png, Max. file size: 10 MB.

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