Faculty Submission Form

The 29th Annual

Contemporary Issues in Urology

presented by Loma Linda University & the University of Southern California

Phone *

Institution: *

Email: *

Learning Objectives: *

Faculty Submission Form

Mailing Address *

Do you have any special A/V needs?

Title of Workshop/Lecture: *

What format will you use:

PowerPoint (Microsoft)

Keynote (Apple)

The following information will be submitted for CME credit and appear in the website and meeting app. Please complete all information requested. Objectives should be based on the quality gap/need the activity is addressing. Please state 2-3 objectives of your activity below. Feel free to contact Maggie Fasbender for assistance or additional information, 909-558-8724.

Full Name and Degree(s): *

Title/Academic Rank: *