2018 Rural Emergency Practice Conference
February 10 - 11, 2018
Mercer University School of Medicine
1250 East 66th Street
Savannah, GA 31404

Speaker Form

Speaker Name: *
Email Address: *
Required entries with every submission*

Contact Information

Mailing address:
Office Phone:
Mobile Phone:
Home Phone:
Assistant's Name:
Assistant's Phone:
Assistant's Email

Please list how you wish to be listed in the program

BIO (used in the Meeting Program and excerpts taken for verbal introduction)

GCEP will either pay a $125 honorarium OR a 1 night stay at the hotel. Please check below which you would prefer:
    $125 honorarium (we will provide you with a check at the meeting)
    1 night stay at the hotel (room and tax will be put on our master bill)

If choosing a hotel stay please indicate your check in and check out date.
   Check in Date:
   Check out Date:

Please fill out the following to continue