Application for Royalty Author Program

1. General information

On behalf of the CSRC, we thank you for your submission of an on-line course. We kindly request you provide the following information.

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* 1. Background information

First name

Last name

Credential(s)

Degree

Institution (Name, city, state)

Major area of study

Job Title

Company/Employer

Street address

Address 2

City/Town

State/Province

Zip/Postal code

Primary phone number

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* 2. Describe your familiarity with the target audience (Respiratory Care Practitioners)

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* 3. Describe your expertise in relation to the topic(s) you wish to present

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* 4. Three objectives that include behavioral words from this link **Note: If viewing the link above on mobile phone, select “back (<)” button to return to Application

Objective 1

Objective 2

Objective 3

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* 5. Declaration of vested interests

Having an interest or a\iliation with an organization does not prevent participation. Past or present, real, or perceived conflict of interest, by having any financial support or gain from a vendor, must be disclosed during presentation. I acknowledge to abide by the criteria.

No, I have no real or perceived conflicts of interests

Yes, I will disclose during presentation

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* 6. FDA Approved Drug and Devices and Assurance Statement

I attest that any conversations pertaining the usage of FDA-approved drugs or devices outside of the approved regulations (known as o\-label use) are clearly explained for learners.

50% of survey complete.