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Presenter Information

Please use the below form to upload your presenter information.

AGES Presenter Form

Presenter Information Form for all AGES events and workshops.

Name*
Title First Last
Email
Phone*
Organisation*
Position
Presenter bio*
We kindly ask that you adhere to the maximum limit of 100 words as this will be used to assist the session chair in introducing you.
Presenter headshot
Please upload a high-resolution headshot (max size 64MB)
Max. file size: 64 MB.
Usage of content*
Without expectation of compensation or other remuneration, you provide consent to use your image and/or presentation or statements made in connection with the AGES Meeting, in its publications, virtual conference portal (if necessary), advertising or other print or electronic media activities including the Internet. This consent includes, but is not limited to: A) Permission to allow access to your presentation via the online virtual conference platform B) Permission to use your name, title and firm/organisation name
Disclosure*
Declaration of financial relationships or commercial affiliations*
Please use the following list to declare your existing or known financial relationships or commercial affiliations. Check the in the appropriate box and indicate the name of the company in the box provided.
- Equity interests (or entitlement to same) of stocks, stock options, royalties, etc, including income from patents or copyrights.
- Service as a director or employment by a commercial organisation, whether or not remuneration is provided for such service
- Sole ownership, partnership or principal of a commercial enterprise
- Ownership of patent(s)
- Receipt of royalties
- Consultant to company including positions on medical or scientific advisory boards
- Honoraria for speaking at company sponsored meetings or events
- Participation in clinical trials
- Support in the form of fellowships, travel grants, gifts, in-kind donations, etc.
- Research grants, partial or full salary support from a commercial organisation for self or employees for whom you are managerially responsible (i.e laboratory technical/research fellow for whom you are managerially responsible)
- Any other type of financial or other relationship
Please indicate the name of the company and/or description of financial relationships or commercial affiliations below*
Signature*
Date*
MM slash DD slash YYYY
Confirmation Email*
Enter Email Confirm Email

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YRD Event Management
PO Box 717 Indooroopilly
QLD 4068 AUSTRALIA

P: +61 7 3368 2422
F: +61 7 3368 2433
ABN: 33 075 573 367

In the spirit of reconciliation, AGES acknowledges the Traditional Custodians of the country throughout Australia and their connections to land, sea, and community. AGES pays respect to their Elders past and present and extend that respect to all Aboriginal & Torres Strait Islander peoples today.

© 2023 Australasian Gynaecological Endoscopy & Surgery Society

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