EmailMe Form - IASA Chapter Speaker Agreement

SPEAKER DETAILS:

Chapter Presenting At *
Chapter Event Month *
Chapter Event Year *
Speaker Name *
First Last
Speaker's Job Title *
Company *
Company location (city, state) *
Speaker email *
Speaker Cell Phone (in case of issues during event) *
### - ### - ####
Speaker Bio - Please provide your professional bio required for CPE (Note for Ethics field of study sessions your bio must include and clearly show your relevant experience or training in this field): *
Speaker photo (please submit high res photo) Photos can be most any size. 8:5:11 - generally size of a document, for 1:1, common size would be 1080 x 1080 pixels. *
_________________________________________________________________

PRESENTATION DETAILS

Presentation Title - Required for CPE
(80 Character limit) *
Session Description - Required for CPE, Provide 2-3 sentences describing what the attendee will gain from this session *
Learning Objectives - THREE (3) Required for every 50 minutes of content. ONLY THE FOLLOWING MEASURABLE VERBS MAY BE USED AS REQUIRED BY NASBA TO QUALIFY FOR CPE CREDIT:

OBJECTIVES MUST BEGIN WITH DEFINE, DETERMINE, DIFFERENTIATE, DISCRIMINATE, DISTINGUISH, IDENTIFY, INDICATE, INTERPRET, RECALL, RECOGNIZE. *
Field of Study Required - Please select one from the drop down box *
Program Level Required - Defined as Basic, Intermediate or Advanced (Intermediate and Advanced require pre-requisites - If selecting these options you must list prerequisites and advanced preparation fields. *
Basic
Intermediate
Advanced
Level of Engagement - Required By NASBA *
Group Discussion
Polling Questions
Instructor-posed questions with time for participation reflection
Use of a case study with different engagement elements throughout the program
Prerequisites - If Program Level above is listed as Intermediate or Advanced, you must list any prerequisites such as education or work experience or knowledge to qualify content for CPE credit.
Advanced Preparation - If Program Level above is listed as Intermediate or Advanced, you must list any prerequisites such as required pre-meeting work that will be provided (or None) to qualify content for CPE credit.

Please select all that apply. Note for Accounting, Auditing or Taxes one or more of the content reviewers or developers must meet one of the below requirements. *

I am a licensed CPA in good standing
I am a Tax Attorney
I am an IRS Enrolled Agent
One of the developers or reviewers of this of content is a licensed CPA,, Tax Attorney or Enrolled Agent
None of the above

License Number if applicable (Required for Accounting, Auditing or Taxes Field of study by at least one presenter or content developer.
I. PARTICIPANT AGREEMENT: OBSERVANCE OF IASA CHAPTER POLICIES
Please check each box below to acknowledge that you have read and understand each section, and will satisfy all of your obligations and responsibilities as an IASA speaker. *
The content of CPE activities does not promote the proprietary interests of any commercial interests.
Content of CPE activities will be restricted to industry issues and operation of devices and should not include product or company names unless essential.
Generic/Trade Names: Presentations must give a balanced view of options. Use of generic names will contribute to this impartiality. If trade names are used, those of several companies should be used rather than only that of a single manufacturer.
Speaker shall own the copyright in all materials provided for, or created by Speaker at the Event except for materials specifically created solely for IASA’s use or materials incorporating IASA’s intellectual property.
Speaker grants IASA a nonexclusive, worldwide, royalty free license to use, reproduce, and distribute the intellectual property in connection with this Event, if they choose to provide their intellectual property.
Speaker grants IASA and its agents and employees a royalty-free, perpetual license to publish, reproduce or otherwise use the Speaker’s name, picture, likeness, comments, or voice for any lawful purpose in all media in connection with the Event.
IASA warrants that usage as described herein shall be solely related to the Event and shall remain appropriate for the insurance industry and shall not in any way be considered derogatory or damaging to the Speaker or Speaker's Company.
Speaker is knowingly and voluntarily taking part in the activities for which their image is being captured and understands the associated requirements.
Speaker releases and waives any and all claims, damages, losses and expenses as a result of, or arising from, their participation.
To the best of Speaker’s knowledge, their presentation does not violate any proprietary or personal rights of others (including any copyright, trademark, or privacy rights), is factual and contains nothing defamatory, unlawful or inappropriate.
Speaker has obtained all necessary licenses and permissions for any third party intellectual property including, but not limited to, music, video or other media shown as part of the Speaker’s presentation.
Speaker shall conduct themselves in a professional and civil manner and in accordance with the IASA's Code of Ethics.
Speaker agrees that no portion of the resulting media created at the Event, containing Speaker’s name, biographical information, quotes, photographs, or recorded interviews needs to be submitted for any approval.
****EXPAND THE REACH OF YOUR SPEAKER EXPERTISE AND TOPIC!!****

Would you be interested in an IASA national podcast episode on this or any other topic? Podcasts are typically 10-20 minute episodes, interview style format coordinated with IASA's podcast host. Podcasts are a great way to increase your exposure as a speaker and expand the reach of your content!

Please note podcasts are for voluntary interest and there are no speaking fees associated with published content. *
Yes, I'd be interested in a podcast on this topic I'm presenting for the IASA chapter..
Yes, I would have interest in a podcast opportunity for another topic.
Not at this time.
If you answered Yes to podcast interest for a topic other than the one you are presenting at this chapter event, please provide a title and brief description of the topic below:
I affirm that I am the speaker named above. *
Yes
No