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AHPBA Speakers Bureau

Please complete the following information to opt-in to the AHPBA Speakers Bureau. This resource will be utilized to source speakers, moderators, panelists and participants for AHPBA Sponsored educational programs and activities. Your submitted information will not be publicly available and will be used at the discretion of leadership.

1. Contact Information

First Name *This question is required.

Last Name *This question is required.

Credentials/Degree *This question is required.

Title

Institution/Company Name *This question is required.

Street Address

Apt/Suite/Office

City *This question is required.

State *This question is required.

Zip

Country *This question is required.

Email Address *This question is required. This question requires a valid email address.

Mobile Phone

2. Please select your AHPBA Member Type: *This question is required.

3. Gender Identity (You may choose multiple): *This question is required.

Agender
Intersex
Man
Non-binary/Genderqueer/Gender fluid
Trans-male
Trans-female
Woman
Other gender category
Prefer not to disclose

4. Ethnicity/Race: Please choose the category you most identify (you may choose multiple) *This question is required.

American Indian or Alaska Native
Asian
Black or African American
Hispanic, Latin or Spanish Origin
Native Hawaiian or Other Pacific Islander
White
Ethnicity Unknown
Other - Write In (Required) Please enter an 'other' value for this selection. * This question is required.

5. Practice Setting *This question is required.

Please enter an 'other' value for this selection. * This question is required.

6. Initial Year of Attending Practice (four digit year format) *This question is required. This question requires a valid number format.

7. Please select your areas of expertise (you may choose multiple): *This question is required.

Basic/Translational Science
Biliary tract
Clinical Trials/Outcomes
Disparities
Health Services Research
HPB Surgical Techniques
Education
Liver
Mentorship
MIS
Pancreas
Research
Robotic
Ultrasound
Other - Write In Please enter an 'other' value for this selection.

8. If you have a novel topic or subject you would like to speak on, please share it here:

9. (Optional) Upload supporting information (CV, Bio, Articles, Research etc.)
Max 3 files

File: {{filename}} delete

10. (Optional) Upload a photo/headshot of yourself

File: {{filename}} delete

11. (Optional) Comments