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Presenter Information Form

Speaker Name:
Name of person filling out this form (if different than above):
Email Address:
Name of Speaker, as you would like it to appear in the program. No degrees. (Examples: "William Durfee" or "Will Durfee"):
Affiliation, including a department or group designator if desired (Examples: "Mechanical Engineering, University of Minnesota" or "Medtronic" or "Cardiac Rhythm Management, Boston Scientific"):
Title of Session:
Presentation Title:
Presentation Abstract (80 words or less):
Speaker Bio (60 words or less):
I give my permission to include my presentation (PowerPoint slides or poster PDF) in the conference CD that all conference attendees receive. Yes
No


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