52nd International Respiratory Congress
Proposal for Program Form
(please submit only one proposal per form)

 
Proposal for:

Lecture (as long as 1 hour)
Workshop (as long as 3 hours)

 

 Symposium (as long as 4 hours)
Other
Track:
(check all that apply) 		Adult Acute Care
Management
Pediatrics/Neonatal
Transport
Continuing Care/Rehab

International
Education
Home Care
Diagnostics
Other

 

Submitted by:
Address:
 
 
City:
State/Province:
Zip/Postal Code:
Country:
Telephone:
Fax:
E-mail:

 

Are you requesting
reimbursement?		 Yes     No
 

If yes, you must write reasons and type of reimbursement requested:

 

Title of Program:

Next, please provide the following:

• Title of each presentation in program
  (if only one presentation in program, write “Same as Title of Program”)
• Name of speaker for each presentation
• Professional affiliation of each speaker (job title, employer, city and state)
• 2–3 sentence description/objectives of each presentation

 
Title of presentation #1:
How much time?
Speaker:
Credential(s):
Professional affiliation:
Description/objectives:

 
Title of presentation #2:
How much time?
Speaker:
Credential(s):
Professional affiliation:
Description/objectives:
 
Title of presentation #3:
How much time?
Speaker:
Credential(s):
Professional affiliation:
Description/objectives:
 
Title of presentation #4:
How much time?
Speaker:
Credential(s):
Professional affiliation:
Description/objectives:
 
  If proposal consists of more than 4 presentations, provide information on additional presentations here:
 
 

Proposals must be received by January 13, 2006. A printable version of this form is also available.