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Event Speaker Form - Imaging Lecture Series 2025-2026

Name and Designation (as you would like it to appear on our website) (Required)

Organization/Institute of Employment (Required)

Title (Required)

Education (Highest Degree) (Required)

Membership in Professional Organizations

Commercial Affiliations and Potential Conflicts of Interest (Required)

Bio / Short Statement of Experience / Publications / Certifications Relating to Activities in this Program (Required)

Headshot

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To the best of my knowledge, my presentation does not violate any proprietary or personal rights of others (including any copyright, trademark and privacy rights), is factually accurate, and contains nothing defamatory or otherwise unlawful. I have the full authority to enter into this agreement and have obtained all necessary permissions or licenses from any individuals or organizations whose material is included or used in my presentation. (Required)

YesNo

I authorize COMP and its affiliates to use my name, likeness, photograph, and biographical data in connection with the use and promotion of the Imaging Lecture Series. (Required)

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