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Biographical Information Form

A Biographical Data Form is required by the OPS Board of Certification and by the Joint Commission on Allied Health Personnel in Ophthahlmology (JCAHPO) for all instructors presenting courses for which continuing education credits (CEC's) are offered. This abbreviated form is necessary to document basic qualifications for teaching the subject matter presented. Neither complete curriculum vite nor extensive lists of accomplishments are required.

Once the data has been entered via this on-line process, it will be forwarded to the OPS BOC and to JCAHPO as part of the OPS application for Continuing Education Credit. The information may also be used for the purpose of speaker introductions before the course.

Requied fields are in Bold Characters.


Name
First Name
Middle Initial
Last Name
Degree / Certification

Preferred Address
Address 1
Address 2
Address 3
City
State / Provence
Postal Code
Country
Email
Daytime Phone

Employment
Employer
Current Position

	Same as Preferred Mailing address
Address 1
Address 2
Address 3
City
State / Provence
Postal Code
Country
Fax

Education
Degree	Institution (Name, City, State)	Major	Year Awarded

Experience
Briefly describe your professional experience, area(s) of expertise, and any certifications, including publications, which qualify you to teach this course.

Presenters

Biographic Information Financial Interest