SPECIAL INTEREST GROUP (SIG) SESSION APPLICATION

First Name *

Last Name *

Email *

 
Name/Title of SIG: *

Must focus on a specific question/issue (exploring a controversial issue, understanding a technique, new technological advance, practice management topic, etc.)  May not be product-related.

 

 
AGS Active Member Sponsor:

 

 
Organizer/Contact Person:
Telephone:
FAX:
Potential Moderator(s):
Potential Speakers (max 3) or Panel (max 5):

 

NOTE:  Organizer, moderator(s) AND each speaker/panelist MUST submit their Financial Disclosure (even if none)
on the American Academy of Ophthalmology’s website at: http://www.agsannex.org/findisc/ags_fd_form.html

 

 
Audio-Visual (AGS Provided):

(e.g., podium, LCD projector and screen)

 

 
Audio-Visual (at Organizer’s expense)

(e.g., flip chart, DVD or VHS player w/monitor, etc)

 

 
Description of SIG: Please submit your description in 250 words or less: )

 

 
Please indicate if you will need any special arrangements.




American Glaucoma Society
P.O. Box 193940 | San Francisco CA 94119
[t] 415.561.8587 [f] 415.561.8531 [e] ags@aao.org