ASCIP Speaker Acceptance FormNOTE: If you have multiple abstracts accepted, please submit a separate form for each abstract. Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastProfessional Credentials *Please enter your professional credentials (MD, RN, etc.) separated by commas. If none, please enter N/AEmail *EmailConfirm EmailAbstract Title - PLEASE SUBMIT A SEPARATE FORM FOR EACH OF YOUR ABSTRACTS ACCEPTED *Presentation Mode *I will present at the ASCIP 2022 ConferenceI must respectfully decline to present in 2022Please let us know why you are declining. *Permission to record presentation for enduring content. *I give my permission for ASCIP to record and use my presentation for enduring content.I do not grant ASCIP permission to record my presentation for enduring content.I attest that the material in my presentation is original content and that I have permission of the author to use/share/distribute all text, images or other material that may have come from other sources. *YesNoI understand that I must register for the conference in order to present. (Except for notified award speakers.) *YesNoSubmit