Name
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Address
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City ST Zip
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Date Time of Presentation
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Amount of Honorarium: ISRC
honorarium is $250.00
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The ISRC will reimburse travel expenses at
$0.50/mile, provide coach airfare if needed, provide overnight
accommodations at the ISRC headquarter hotel for those traveling
60 miles or more, and $30.00/day for expenses when
necessary unless otherwise approved by the ISRC Program Committee.
(No expenses will be reimbursed without receipts.)
Lodging needed for night(s)
of
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(One night per day of presentation is
provided for speakers sponsored by the ISRC.) Please see
the most updated information regarding conference housing:
Click Here |
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Your signature on this
letter of agreement shall be enforced according to the laws of
the State of Illinois. Enter your name and initials
below. |
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Tax ID or SSN (required
to supply you with tax form 1099). It is recommended that you
provide this information at the conference and do not enter
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If you have an outside sponsor (ISRC NOT paying
your honorarium, lodgings or
expenses.) Please select one
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Name of the Sponsoring Agency:
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Representative Name for the Sponsoring Agency
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Representative’s Contact phone number
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A presenter may
have an interest in or affiliation with an
organization which does not prevent him or her from
making a presentation; however, the audience must be
informed of this relationship before the presentation
(in the introduction). Do you have significant
financial (ownership) interest in a product you are
discussing or an employment or research interest?
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Yes, I have the following interest(s):
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How will you keep the
presentation free from bias (example: disclaimer
on slide):
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In lieu of print handouts, I give the ISRC
permission to post my presentation on the ISRC web
page for viewing by conference attendees |
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In lieu of print handouts, I will
provide my contact information ( e-mail, etc) on
the final slide of my presentation. This will
allow conference attendees to contact me directly
to obtain an electronic copy of my presentation |
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I do not want my presentation made
available by any means other than when I have
presented it for the agreed date and time of this
conference |
Title of Lecture
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Learning Objective 1:
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Learning Objective 2:
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Audio Visual Needs:
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Computer with Microsoft
Power Point |
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Support for Apple/Mac
Computer ( assuming that you bring your
own MAC BOOK) |
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Internet Access (paid for
by Speaker/ or Company Sponsor). The ISRC
can provide a cost estimate upon request |
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Sound/Audio Support for Presentation |
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Lapel Microphone |
| Laser Pointer |
Enter initials and date
here and email address here:
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Please provide a Biography of your
self.Your moderator assigned to you
will introduce you and use this brief
biography for your introduction. We
ask that along with your name that you
provide the following:
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Professional Title
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Professional
Credentials, Fellowships,
Diplomate’s etc
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Current place(s) of
Employment
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Noteworthy
accomplishments
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Other pertinent
information supporting your
expertise
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You may use the space
below to write out or cut-n paste
your response from a resume or CV.
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If you choose, you
may attach a separate document and
forward it to me.
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