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         Job Title 

     Business Name  (Required)

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Your Organization Type Select OneMedical PracticeHospitalIntegrated Delivery SystemMSOIPA or NetworkManaged Care Co. or HMOConsultantOther

Your Primary Area Select OneMetroRuralMixed

Your Organization Size
Number of Active Physicians on Staff: 
Number of Beds:                       
Number of Enrolled Lives:             
Practice Size or other Measurement:   

Years Experience
Working with Physicians?   
In Current Position?       
In Health Industry?        

Your Highest Level of Education Completed 

Are you a Member of The American Academy of Medical Management Select OneYesNo

Have you attended any AAMM Seminars? Select OneYesNo

If Yes, which one(s) 

Session Information
For your session, who is the primary audience?Medical PracticeIntegrated Delivery SystemHospitalOther

Also regarding the primary audience, please check one to three
which your proposal targets:
Physicians             Medical Staff Affairs
Senior Management      Business Development/Marketing
Board                  Physician Relations or Services
Operations             Physician Recruitment
Finance                Other

Please list three possible titles of your session (same session,
with three title versions to help with promotional brochure creation).


Please give a solid one-paragraph description:


What is the main concept attendees will have learned?


List at least 7 benefits or objectives:


For which session is this most appropriate?IntermediateAdvanced

Has, or will, this session be presented elsewhere? If so, where?

Your AV Requirements:

Length of Program you desire?Single Session (1 hour, 15 min.)Double Session (2 hours, 30 min)Full Day Session (6 hours)

Other conferences where you have spoken or plan to speak:


Other Speaking/Teaching Experience:


General Release
I agreeI disagreeHereby assign to AAMM/MSD, Inc. The full authority to use,
transfer and assign the audio, video and handouts of this session without
any restriction whatsoever, including but not limited to, freely edit, see,
and distribute. I also give AAMM.MSD, Inc. exclusive right without limitations
as to time, to use my name, voice and/or photo to video image for the 
purpose of promoting, publicizing and advertising. I understand my commitment
to produce an excellent presentation for the program and the importance of well-
developed handout materials. If chosen, I will be highly responsive to telephone
calls, emails and faxed messages, within 24 hours if at all possible. I understand
that if chosen, this agreement is with me, and I may not arbitrarily appoint
someone else to speak/teach in my stead. I further understand that if I do not
fulfill my requirements to meet these obligations, I will be removed as a faculty
member.
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