SPEAKER LETTER OF AGREEMENT
FamMed Forum 2022

This agreement is made between the New Jersey Academy of Family Physicians (NJAFP), hereafter referred to as the “Provider,” and the presenter signed below hereafter referred to as the “Speaker” and serves to confirm participation in the NJAFP FamMed Forum on April 1, and April 2, 2022.

Presentation Title *

Personal Information:

Presenter's Name *

First

Last

Professional Title: *

Organization: *

Street Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Day of Contact Phone Number: *

Production Timeline:

Deliverable Deadlines:

Speaker Letter of Agreement Form Completed, Signed, and Submitted - Friday, March 4, 2022
Faculty Full Disclosure Form Completed, Signed, and Submitted - Friday, March 4, 2022
Brief Session Description - Friday, March 4, 2022
Brief Bio and Headshot - Friday, March 4, 2022
Three (3) Learning Objectives - Friday, March 11, 2022
Three (3) Post-Test Questions - Friday, March 11, 2022
First Draft of PPT Presentation (on FamMed Forum slide deck template provided) - Friday, March 18, 2022
Final PPT Presentation Due (on FamMed Forum slide deck template provided) - Friday, March 25, 2022

Agreement:

Please initial to indicate your agreement with the following statements:

Declaration of Full Disclosure: All speakers must make a statement of full disclosure of financial conflicts of interest. Completed and signed disclosure statements must be received by staff no later than the date listed above. If a disclosure of conflict of interest is not received, the speaker will be asked to step down. *

Review of Educational Materials: In accordance with ACCME requirements, all educational materials including slide presentations must be reviewed by the CME Department or Planning Committee. To ensure time for review and revisions (if necessary), draft materials must be submitted no later than the date listed above. *

Copyright Acknowledgement: The Speaker will obtain written permission for use of any copyrighted material used in his/her presentation. Speaker affirms that all necessary approvals allowing reproduction of materials have been attained. It is suggested that the speaker protect his/her material with a copyright by putting the following language on the bottom of the first page: © 2022 BY (SPEAKER NAME). The Provider takes no responsibility for registering the speaker’s copyright. *

Release of Materials: Speaker provides authorization to share with attendees his/her slides and/or handouts and/or other educational materials that support the speaker’s presentation *

Photographic/Media Release: Speaker agrees that his/her presentation may be recorded, and the recorded content may be shared with attendees/learners. Speaker grants the Provider permission to use their likeness in photograph(s)/video in any and all publications, whether in print or electronically and in all other media, whether now known or hereafter existing, controlled by the Provider. The Speaker will make no monetary or other claim against the Provider for sharing recorded content and the use of his/her photograph(s)/video. *

Speaker Information: Speaker will provide a CV, bio, and headshot (high resolution JPEG file) to be used for planning and publicity. These files will be provided to staff no later than the date listed in the production timeline. *

Signature *

Date

SPEAKER LETTER OF AGREEMENT
FamMed Forum 2022

Personal Information:

Production Timeline:

Agreement:

Upcoming Events

2024 Annual Meeting

SPEAKER LETTER OF AGREEMENT FamMed Forum 2022

Personal Information:

Production Timeline:

Agreement:

SPEAKER LETTER OF AGREEMENT
FamMed Forum 2022