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Below is the application to be an Instructor at the Goldfarb Foundation's 2021 Clinical Conference.  All details for the event are included in this letter, please read the letter in its entirety before completing the application.  If you encounter issues with the application, contact Lara Beer-Caulfield.

Applications must be received by 12:00 pm on Friday, January 8, 2021.  The applications will be reviewed in mid-January.  The Foundation will reach out to those whose applications have been accepted in late winter.

Clinical Conference Instructor Application

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  • CONTACT INFORMATION




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  • CREDENTIALS & MEMBERSHIPS










  • FINANCIAL DISCLOSURES


  • If applicable, check which type of disclosure you need to make and then list the relevant names of the companies/organizations.





  • If you do have a financial interest to disclose, enter the name of the company below that the conflict is with- this area is NOT for you enter your name unless your name happens to be the exact same name as that of the company.

  • LECTURE PREFERENCES & INFORMATION






  • Complete the information below pertaining to the lecture you would like to present. You must enter the title and description of at least one lecture and are welcome to complete the information for a second lecture.

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    • ATTESTATION & SUBMISSION

    • By signing your name below, you are signing this application and attesting that you are the speaker applying and not a third party organization submitting the information on behalf of another person.

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    Phone : 717-763-7665
    Fax : 717-761-4091
    Email: lara@ppma.org
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    Camp Hill, PA 17011
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