Faculty Interest Form
Thank you for your interest in serving as faculty for a Duke CME activity. We will contact you once an opportunity arises.
1
Please provide your full contact information.
Name: 
Organization: 
Address 1: 
Address 2: 
City/Town: 
State/Province: 
Zip/Postal Code: 
Country: 
Email Address: 
2
What is your profession?
Physician
Physician Assistnat
Nurse Practitioner
Nurse
Pharmacist
Other, please specify
3
What role(s) would you be interested in serving in?
Activity chair
Speaker/presenter
Planning committee member
Author
Content reviewer
Other, please specify
4
What specialities/areas would you be interested in developing content for?
Allergy
Anesthesiology
Cardiology
Clinical Pharmacology
Community & Family Medicine
Dermatology
Emergency Medicine
Endocrinology
Gastroenterology
General Surgery
Geriatrics
Hematology
Infectious Diseases
Internal Medicine
Nephrology
Neurology
Neurosurgery
Obstetrics & Gynecology
Oral & Maxillofacial Surgery
Oncology
Ophthalmology
Orthopaedic Surgery
Otolaryngology
Pathology
Pediatrics
Plastic Surgery
Psychiatry
Pulmonary
Radiation Oncology
Radiology
Rheumatology & Immunology
Urology
Vascular Surgery
Women's Health
Other, please specify
5
Comments:

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