AMWA102 Abstract Submission Form

AMWA 102nd Annual Meeting

Abstract Submission Form
2017 Conference Dates: Friday, March 31st - Sunday, April 2nd
Read the following before proceeding:

- No duplicates of presentations from previous AMWA meetings will be accepted.

- No late abstracts will be accepted. Abstract deadline: 11:59pm on December 22, 2016.

- Please refer to formatting rules for your poster on the AMWA website.

- Please enter your abstract information as accurately as possible as it will not be able to be changed after submission of this form.

Please note: There will be a non-refundable $20.00 abstract submission fee payable via credit card at the end of this form.
Personal Information
Name*

First Name Last Name
E-mail*
Phone Number*

Area Code Phone Number
Division*
Institution/Affiliation*
Title*
If you selected "Other", please describe below:
Program
If you selected "Other", please describe below:
Year of Study
Do you or any of your co-authors have any financial disclosures?*
If you have financial disclosures, please describe below:
How many co-authors are listed on your abstract NOT including yourself (Please enter a numerical value between 0 and 10. ex. 3)?*
Have ALL abstract authors agreed to poster submission & abstract publication in AMWA Conference Abstract Booklet, which may be published online or in print? (ALL authors will be notified of your submission and must sign off for abstract to be eligible for acceptance.)*
Please enter the names and email addresses of the co-authors in the text fields below (NOT including yourself). These fields will only be present if you have entered a numerical value other than 0 above (do not worry about entering the authors in the correct order here, however, please make sure they are listed in the correct order in the abstract submission box).
Author 1 Name
Author 1 Email
Author 2 Name
Author 2 Email
Author 3 Name
Author 3 Email
Author 4 Name
Author 4 Email
Author 5 Name
Author 5 Email
Author 6 Name
Author 6 Email
Author 7 Name
Author 7 Email
Author 8 Name
Author 8 Email
Author 9 Name
Author 9 Email
Author 10 Name
Author 10 Email
Type of Abstract*
If you selected "Other", please describe below:
Presentation/Poster Title*
Will you have multiple presenters?*
Please enter the names and email addresses of other presenters.
In which division would you like your poster to be judged? (e.g., if you are an attending physician submitting an abstract, but a resident/student will be presenting the poster and would like to be judged accordingly)
You will be assigned a day and a time to present your poster. If you absolutely cannot present on a particular day, please indicate it below. We will do our best to accommodate you.
RESIDENT ONLY- Are you interested in being considered for an oral presentation? (Please note this excludes you from presenting a poster and being eligible for a poster award)

YesNo
Abstract

Please enter your abstract below. Once submitted, your abstract cannot be altered in any way and will be published as typed.
Your abstract will be published in the abstract booklet as it appears below. All abstracts must be formatted as follows (please note that author names do not count against the word limit):

For Scientific Research: Authors' names (ex. Smith, Jane, L.), Hypothesis, Methods, Results, Conclusions

For Clinical Cases: Authors' names (ex. Smith, Jane, L.), Case, Conclusions, Clinical Significance

*Please remember to place the author names in the correct order/in the order they will appear on your poster (e.g. the primary author is listed first, etc.), followed by your abstract text.*
Please limit your abstract text to ≤300 words (an additional 150 words are available for author names, to be typed at the beginning of the abstract).*

0/450
Agreement and Electronic Signature

By submitting this application, I affirm that I will be available to present during any time on March 31, April 1, and April 2, at the 2017 Annual Meeting. I affirm that I have reviewed the application instructions and that the facts set forth here are true and complete. I also acknowledge that my $20.00 abstract fee is required to participate, and that it is non-refundable in the circumstance that I am unable to attend. The author approvals below are to be filled out by the authors I listed. I understand that an email has been sent to each of the authors listed with instructions to do so.
Signature (Electronic)*

Abstract submission fee $20.00 per abstract, non-refundable. YOUR ABSTRACT WILL ONLY BE CONSIDERED IF SUBMISSION FEE IS PAID.

Abstract Submission Fee$20.00

Total $0.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

YOUR SUBMISSION AND PAYMENT ARE NOT COMPLETE UNTIL YOU CLICK THE SUBMIT BUTTON BELOW:

Author 1 Approval
I approve this abstract submission for the AMWA Centennial Meeting Poster Presentation. I understand that, if accepted, the submitting author is required to attend the Centennial Meeting in April 2015 and that the abstract will be published in the online AMWA Poster Abstract Booklet.

Please click "submit" above after providing your electronic signature.
Author 1 Signature (Electronic)

Author 2 Approval
I approve this abstract submission for the AMWA Centennial Meeting Poster Presentation. I understand that, if accepted, the submitting author is required to attend the Centennial Meeting in April 2015 and that the abstract will be published in the online AMWA Poster Abstract Booklet.

Please click "submit" above after providing your electronic signature.
Author 2 Signature (Electronic)

Author 3 Approval
I approve this abstract submission for the AMWA Centennial Meeting Poster Presentation. I understand that, if accepted, the submitting author is required to attend the Centennial Meeting in April 2015 and that the abstract will be published in the online AMWA Poster Abstract Booklet.

Please click "submit" above after providing your electronic signature.
Author 3 Signature (Electronic)

Author 4 Approval
I approve this abstract submission for the AMWA Centennial Meeting Poster Presentation. I understand that, if accepted, the submitting author is required to attend the Centennial Meeting in April 2015 and that the abstract will be published in the online AMWA Poster Abstract Booklet.

Please click "submit" above after providing your electronic signature.
Author 4 Signature (Electronic)

Author 5 Approval
I approve this abstract submission for the AMWA Centennial Meeting Poster Presentation. I understand that, if accepted, the submitting author is required to attend the Centennial Meeting in April 2015 and that the abstract will be published in the online AMWA Poster Abstract Booklet.

Please click "submit" above after providing your electronic signature.
Author 5 Signature (Electronic)

Author 6 Approval
I approve this abstract submission for the AMWA Centennial Meeting Poster Presentation. I understand that, if accepted, the submitting author is required to attend the Centennial Meeting in April 2015 and that the abstract will be published in the online AMWA Poster Abstract Booklet.

Please click "submit" above after providing your electronic signature.
Author 6 Signature (Electronic)

Author 7 Approval
I approve this abstract submission for the AMWA Centennial Meeting Poster Presentation. I understand that, if accepted, the submitting author is required to attend the Centennial Meeting in April 2015 and that the abstract will be published in the online AMWA Poster Abstract Booklet.

Please click "submit" above after providing your electronic signature.
Author 7 Signature (Electronic)

Author 8 Approval
I approve this abstract submission for the AMWA Centennial Meeting Poster Presentation. I understand that, if accepted, the submitting author is required to attend the Centennial Meeting in April 2015 and that the abstract will be published in the online AMWA Poster Abstract Booklet.

Please click "submit" above after providing your electronic signature.
Author 8 Signature (Electronic)

Author 9 Approval
I approve this abstract submission for the AMWA Centennial Meeting Poster Presentation. I understand that, if accepted, the submitting author is required to attend the Centennial Meeting in April 2015 and that the abstract will be published in the online AMWA Poster Abstract Booklet.

Please click "submit" above after providing your electronic signature.
Author 9 Signature (Electronic)

Author 10 Approval
I approve this abstract submission for the AMWA Centennial Meeting Poster Presentation. I understand that, if accepted, the submitting author is required to attend the Centennial Meeting in April 2015 and that the abstract will be published in the online AMWA Poster Abstract Booklet.

Please click "submit" above after providing your electronic signature.
Author 10 Signature (Electronic)
Should be Empty:

AMWA 102nd Annual Meeting

Personal Information

Abstract

Agreement and Electronic Signature